A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the client's room and closed door to client's room.

Exhibits

Complete the following sentence by using the lists of options.

The nurse is at risk for

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as evidenced by

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.

Rationale:

A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output requires assessment for possible drug reaction or hematuria, but this may not be immediately life-threatening compared to hypoglycemia.

B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL is at risk for hypoglycemia, which requires prompt assessment and intervention to prevent severe complications.

C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache should be assessed, but the calcium level and headache are less urgent compared to immediate treatment needs for hypoglycemia.

D. A client who was administered acyclovir for cellulitis reports pain in the affected leg may require assessment for infection or medication side effects, but this is less critical than addressing hypoglycemia.

Rationale:

A. Withholding a dose of narcotic pain medication when there is respiratory depression aligns with nonmaleficence, as it prevents further harm by not exacerbating the client's respiratory issues.

B. Discussing advance directives is important but is more related to autonomy and respect for the client’s wishes rather than nonmaleficence.

C. Providing comfort care is a supportive measure but does not specifically address nonmaleficence in terms of preventing harm.

D. Allowing unlimited visitation respects family wishes but does not directly relate to the principle of nonmaleficence regarding the client’s immediate medical needs.