A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A. "I should consume fish once per week": While consuming fish is beneficial, particularly fatty fish high in omega-3 fatty acids, this alone is not a comprehensive strategy for preventing hypertension.
B. "With a BMI of 30, I should focus on maintaining my current weight": With a BMI of 30, which is classified as obese, the focus should be on reducing weight rather than maintaining it to help prevent hypertension.
C. "I should exercise for 30 minutes three times per week": The recommended amount of exercise for cardiovascular health is at least 150 minutes of moderate-intensity exercise per week, which is more frequent than three times per week.
D. "I should consume no more than 2,000 milligrams of sodium per day": This is correct as reducing sodium intake to no more than 2,000 milligrams per day is a key strategy for preventing and managing hypertension.

Rationale
• Assist the client to the bathroom.
• Non-essential: The client’s current condition indicates severe changes, including a significant drop in consciousness and worsening vital signs. Immediate priorities involve stabilization and monitoring rather than assisting with bathroom needs.
• Initiate seizure precautions.
• Anticipated: The client’s deteriorating condition, including restlessness, agitation, and decreased level of consciousness, increases the risk of seizures. Initiating seizure precautions is appropriate to ensure safety.
• Record GCS every 15 min for the first 4 hr.
• Anticipated: The Glasgow Coma Scale (GCS) score of 9 indicates a significant decrease in consciousness. Frequent monitoring of GCS is crucial to assess changes in neurological status and to guide further intervention.
• Elevate the head of the bed.
• Anticipated: Elevating the head of the bed can help with cerebral perfusion and decrease intracranial pressure. This is a common intervention for clients with neurological issues to improve comfort and safety.
• Keep the client's head in midline position.
• Anticipated: Maintaining a midline position helps ensure optimal cerebral perfusion and reduces the risk of complications. It is particularly important in clients with neurological changes.
• Encourage the client to cough.
• Non-essential: Given the client's current level of consciousness and agitation, encouraging coughing might not be appropriate and could cause further distress or complications.
• Decrease oxygen to 1.5L/min via nasal cannula.
• Contraindicated: The client’s oxygen saturation has dropped to 90% despite receiving 6 L/min of oxygen. Decreasing the oxygen flow could further impair oxygenation. The priority is to maintain or increase oxygen levels to ensure adequate oxygenation.