A nurse is assisting with the care of an adolescent.

Exhibits

Complete the following sentence by using the lists of options.

The adolescent is at risk for developing

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evidenced by

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A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.

A. "I can have two glasses of wine with dinner." While moderate alcohol consumption may be acceptable, guidelines typically recommend limiting alcohol intake to one drink per day for women. Two glasses of wine may exceed this recommendation, and excessive alcohol can contribute to higher blood pressure.
B. "I will set my blood pressure goal at 130 over 84." The target blood pressure for individuals with mild hypertension is usually less than 130/80 mmHg. Setting a goal of 130/84 does not meet the recommended guidelines for managing hypertension effectively.
C. "I should exercise for 15 minutes two times per week!" While any exercise is beneficial, the general recommendation for adults is to engage in at least 150 minutes of moderate-intensity aerobic activity each week, which translates to about 30 minutes on most days. Exercising only two times per week for 15 minutes is insufficient for achieving cardiovascular health and blood pressure management.
D. "I should decrease my salt intake to 2 grams per day." Decreasing salt intake to 2 grams per day indicates an understanding of dietary recommendations for managing hypertension. The American Heart Association recommends limiting sodium intake to no more than 2,300 mg per day, and further reduction to 1,500 mg may be beneficial for those with hypertension. Reducing salt can help lower blood pressure effectively.