A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

Rationale:

• Relationship status: BPD is marked by instability in relationships, often due to intense fear of abandonment or difficulty managing emotional attachments. Sudden breakups or conflict with close partners are common, especially during emotional crises.
• Concerns about coworkers: Individuals with PPD often misinterpret benign actions of others as malicious or threatening. Persistent beliefs that others are conspiring against them—despite little or no evidence—are core features of the disorder.
• Client statement: Impulsivity is a diagnostic criterion for BPD. Risky behaviors like sudden, financially irresponsible purchases are driven by difficulty regulating emotion and can reflect an effort to escape negative feelings.
• Skin alterations: Recurrent self-harm (e.g., superficial cutting) is a hallmark of BPD, typically used to cope with overwhelming emotional distress, feelings of emptiness, or perceived rejection or abandonment.
• Behavior pattern: Blunted affect and lack of improvement may reflect emotional withdrawal seen in both BPD and PPD. In BPD, emotional dysregulation underlies these symptoms; in PPD, chronic mistrust can lead to guarded, affectively flat behavior and resistance to help.

Rationale:

A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.