A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

A. Collect a urine sample from the client: While collecting a urine sample may be necessary for further assessment, it is not the priority in this situation. The client's symptoms of lower back pain, feeling chilled, and itching suggest a potential transfusion reaction, which requires immediate attention to ensure the client's safety. Therefore, collecting a urine sample is not the most appropriate initial action.

B. Return the platelet bag and tubing to the blood bank: Returning the platelet bag and tubing to the blood bank may be necessary after stopping the infusion, but it is not the first action the nurse should take. Stopping the infusion and assessing the client's condition are the immediate priorities to address the potential transfusion reaction.

C. Notify the provider: While it is important to notify the provider about the client's symptoms and the suspected transfusion reaction, this action should follow after stopping the infusion and assessing the client's condition. Immediate intervention to ensure the client's safety takes precedence over contacting the provider.

D. Stop the infusion: This is the correct action. The client's symptoms of lower back pain, feeling chilled, and itching are indicative of a potential transfusion reaction, such as febrile non-hemolytic transfusion reaction or allergic reaction. The immediate priority is to stop the infusion to prevent further administration of platelets and assess the client's condition. This action takes precedence over other interventions as addressing the client's safety and well-being is paramount in the event of a transfusion reaction.

A) Anxiety: Anxiety is a subjective finding because it represents the client's perception of their emotional state. It is a feeling of unease, worry, or fear, which the client reports experiencing. Subjective findings are based on the client's self-report or feelings.

B) Alert: Being alert is an objective finding because it refers to the client's level of consciousness and responsiveness to stimuli. In this scenario, the nurse assesses that the client is alert based on their ability to respond appropriately to questions and stimuli in the environment.

C) Pacing: Pacing is an objective finding because it describes observable behavior. In this case, the nurse observes the client pacing in the room, which is a physical activity that can be seen or measured.

D) Restless: Restlessness is an objective finding because it describes observable behavior. The nurse assesses that the client appears restless based on their observed behavior of pacing in the room. Restlessness is a physical manifestation of the client's anxiety and is observable by others.