A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

Rationale

1. Ask the client about the content of their hallucinations: Indicated
   • Understanding the content of hallucinations can help in assessing the severity and nature of the client's condition, and in planning appropriate interventions.
2. Instruct the client on expected hygiene practices: Indicated
   • Encouraging and educating the client about personal hygiene is important for their overall well-being and social interactions.
3. Allow the client to watch TV at a high volume: Contraindicated
   • High volume and excessive stimulation can exacerbate symptoms of schizophrenia, such as hallucinations and agitation.
4. Assess the client for suicidal ideation: Indicated
   • Regular assessment for suicidal thoughts is crucial, even if the client initially denies them, as their mental state can change.
5. Place the client in a room near the activity: Contraindicated
   • A quieter environment is generally more beneficial for clients with schizophrenia to reduce overstimulation and stress.

A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.

B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.

C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.

D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.

E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.

F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.

G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.