A nurse is caring for a client who has hypoglycemia.
The nurse should monitor the client for which of the following adverse effects of hypoglycemia?

Choice A rationale:

Reporting a penicillin allergy in the client's history is essential when the client is prescribed cefaclor. Cefaclor is a cephalosporin antibiotic, and individuals with a documented penicillin allergy may have an increased risk of cross-reactivity and allergic reactions to cephalosporin antibiotics. Therefore, it is crucial to report a penicillin allergy to the provider to evaluate the potential risks and consider alternative antibiotics if necessary.

Choice B rationale:

An egg allergy is not directly relevant to the prescription of cefaclor. While allergies to various substances can be important in healthcare, egg allergy is not a contraindication or concern when prescribing cefaclor. Therefore, it does not require specific reporting in this context.

Choice C rationale:

Tendonitis is not directly related to the prescription of cefaclor. Tendonitis is an inflammatory condition affecting tendons and is not typically a contraindication for cefaclor or other cephalosporin antibiotics.

The correct answer is choice A and E.

Choice A rationale:

The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.

Choice B rationale:

Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.

Choice C rationale:

Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.

Choice D rationale:

Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.

Choice E rationale:

Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.