A nurse is assisting with the care of a client who is receiving a blood transfusion. The nurse should monitor for which of the following findings as an indication the client is having an acute hemolytic reaction?

Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.

Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.

Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.

Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.

Choice A reason: Nurse self-awareness is crucial in providing care for individuals with personality disorders to avoid countertransference.

Choice B reason: Trust is a fundamental component of the nurse-client relationship and is necessary for effective care.

Choice C reason: Limit setting is essential for maintaining professional boundaries and providing structure in the therapeutic relationship.

Choice D reason: Vague communication is not therapeutic and can lead to misunderstandings and increased feelings of inferiority, which is not conducive to treatment.