A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

Rationale:

• Heart rate: A heart rate of 118/min indicates tachycardia, which may be a compensatory response to hypovolemia or blood loss. Combined with low blood pressure and low hemoglobin/hematocrit, it raises concern for active gastrointestinal bleeding and hemodynamic instability.
• Stool results: A positive hemoccult test confirms gastrointestinal bleeding, especially when paired with the client’s report of dark, tarry stools (melena). This requires prompt evaluation and may indicate upper GI bleeding, such as from a peptic ulcer.
• Current medications: The client is taking high-dose ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), which can cause or worsen gastric ulcers and bleeding. Continued use should be stopped immediately and replaced with safer alternatives.
• WBC count: The WBC count is within the normal range and does not indicate an active infection or inflammatory process at this time. It does not require urgent follow-up compared to other findings.
• Hemoglobin and hematocrit: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting blood loss likely due to GI bleeding. These values warrant urgent follow-up and possible transfusion depending on symptoms and stability.
• Temperature: The client’s temperature of 37.5°C (99.5°F) is slightly elevated but within normal limits and not a priority concern. There are no signs of infection or fever that require immediate follow-up.
• Blood pressure: A BP of 90/50 mm Hg indicates hypotension, which is concerning in the context of GI bleeding and low hemoglobin. This may reflect hypovolemia and requires prompt fluid management and monitoring.
• Respiratory rate: A respiratory rate of 18/min is within normal limits and does not indicate respiratory distress. It does not require immediate follow-up in this context.

Rationale:

A. "Your child should have surgery in 7 to 10 days to remove the tumor.": Surgical removal of the tumor is a priority and is usually scheduled promptly after diagnosis, not delayed by a week or more. Early intervention reduces the risk of tumor rupture or metastasis.

B. "You should not palpate your child's abdomen prior to surgery.": Avoiding abdominal palpation is crucial because Wilms’ tumors are highly vascular and encapsulated. Palpation could cause rupture, leading to tumor cell spread into the peritoneal cavity and increasing the risk of metastasis.

C. "You should give your child captopril 200 mg PO daily.": Captopril is not a standard medication in the treatment of Wilms’ tumor. It is an antihypertensive that may be used if the child has associated hypertension, but the dosage listed is excessive for pediatric use and should not be prescribed without specific indications.

D. "Your child will not require further treatment after removal of the tumor.": Most children require additional therapy, such as chemotherapy and/or radiation, depending on tumor staging. Surgical removal alone is rarely curative, particularly in advanced or bilateral cases.