A nurse is caring for a client who has a spinal cord injury.

Nurses' Notes 0600:

Adventitious lung sounds auscultated in lower lobes bilaterally. Spirometry encouraged. Cough productive for clear sputum.

1000:

Cough productive for clear sputum following incentive spirometry and coughing exercises. Face and neck flushed. Client reports headache.

Abdomen distended. Last bowel movement was 2 days ago with hard stool. Provider Prescriptions

Nifedipine 30 mg PO for blood pressure greater than 150/100 mm Hg and notify provider Acetaminophen 650 mg PO q4 hr PRN pain

For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

A. Correct. The priority is to assess the client for any adverse effects of the medication, such as a drop in blood pressure, which can result in orthostatic hypotension.

B. Incorrect. Nasal congestion is not typically associated with an overdose of valsartan.

C. Incorrect. While obtaining laboratory results might be necessary, it is not the priority action in this situation.

D. Incorrect. Monitoring urine output is important, but assessing for potential complications related to the overdose takes precedence.

Choice B rationale:

Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.

Choice A rationale:

Thinking about a positive outcome to a stressful situation is a cognitive-behavioral technique that can help shift the client's focus from negative thoughts to positive ones. While this technique can be beneficial, it does not specifically pertain to progressive relaxation as described in choice B.

Choice C rationale:

Picturing taking the stress and pushing it out of the feet is a visualization technique, which can be helpful for some individuals in managing stress. However, it is not a component of progressive relaxation as described in choice B.

Choice D rationale:

Focusing on a pleasant memory and expressing emotions in writing is a form of journaling or expressive writing, which can be a therapeutic technique for managing emotions and stress. While it can be a helpful strategy, it is not the same as progressive relaxation involving muscle tension and release.