A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

 

 

 

A. Constipation is not typically associated with TPN because the client is receiving nutrients intravenously rather than through the gastrointestinal tract.

B. Respiratory depression is not a direct complication of TPN administration.

C. Hypotension is not a common complication of TPN unless associated with fluid shifts or infection.

D. Electrolyte imbalance is a potential complication of TPN due to the high concentrations of glucose, electrolytes, and other nutrients. Rapid infusion, improper formulation, or abrupt discontinuation can lead to imbalances in sodium, potassium, calcium, magnesium, and phosphate. Frequent monitoring of laboratory values is essential to prevent metabolic complications.

- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.