A nurse is caring for a client who had total hip arthroplasty 2 days ago. Which of the following actions should the nurse take

Rationale:

A. "I will provide my child with high-fiber foods": While fiber is important for overall health, many high-fiber grains contain gluten, which must be avoided in celiac disease. Offering high-fiber foods without confirming they are gluten-free could cause intestinal damage and symptoms in the child.

B. "I will give my child whole wheat toast and milk for breakfast": Whole wheat contains gluten, which triggers an autoimmune response in children with celiac disease. Serving whole wheat toast is unsafe and indicates a misunderstanding of dietary restrictions for managing this condition.

C. "I will keep my child on a gluten-free diet": A strict gluten-free diet is the primary treatment for celiac disease. Eliminating all sources of wheat, barley, rye, and derivatives allows intestinal healing, prevents symptoms, and reduces the risk of long-term complications, showing correct understanding of dietary management.

D. "I will administer digestive enzymes with meals and snacks.": Digestive enzymes are not a standard treatment for celiac disease and do not prevent the autoimmune response caused by gluten. The focus should remain on dietary avoidance of gluten rather than relying on enzyme supplementation.

Rationale:

A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.

B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.

C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.

D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.