A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

A. This response does not address the adolescent's underlying question and may come across as dismissive.

B. This response avoids addressing the adolescent's question and suggests changing the subject.

C. This response is somewhat confrontational and does not explore the adolescent's feelings or concerns.

D. This response acknowledges the adolescent's curiosity and opens the door for further discussion about why the nurse chose to engage with them. It invites the adolescent to explore their feelings and thoughts.

A. This client's symptom of shortness of breath while ambulating indicates possible worsening heart failure, which requires prompt assessment but is not immediately life-threatening.

B. Vomiting coffee-ground emesis suggests upper gastrointestinal bleeding, which could be

indicative of a serious condition such as a gastrointestinal ulcer or tear and requires immediate assessment to determine the cause and initiate appropriate treatment.

C. While urinary retention in a client with benign prostatic hyperplasia requires attention, it is not as urgent as upper gastrointestinal bleeding.

D. Green drainage from the T-tube in a client who had an open cholecystectomy may indicate bile leakage, which requires assessment and intervention, but upper gastrointestinal bleeding takes precedence due to its potential for rapid deterioration.