A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?

Choice A rationale:

A client with obsessive-compulsive disorder being upset about a change in daily routine is concerning but does not present an immediate threat to their physical health or require urgent attention compared to a potential medical emergency like a sore throat.

Choice B rationale:

Clozapine, an atypical antipsychotic, can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. Sore throat could be an early sign of this serious adverse effect. Therefore, a client taking clozapine reporting a sore throat requires immediate evaluation to rule out agranulocytosis, which can progress rapidly if not addressed promptly.

Choice C rationale:

A client with narcissistic personality disorder mocking others during group therapy is disruptive and inappropriate behavior but does not require immediate attention unless it escalates into a situation that threatens the safety of others or the therapeutic environment.

Choice D rationale:

A client with depressive disorder requiring assistance with activities of daily living (ADLs) needs support and care, but this does not indicate an urgent situation. While assistance with ADLs is important for the client's well-being, it is not a priority over a potential medical emergency like agranulocytosis.

The correct answer is choice d. Increasingly severe headache.

Choice A rationale:

Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.

Choice B rationale:

Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.

Choice C rationale:

Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.

Choice D rationale:

Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.