A nurse is evaluating a client's acceptance of having a new ileostomy.
Which of the following statements by the client indicates acceptance?

Choice A rationale:

"Provide homeschooling for your child" is not relevant information for the guardians of a child with cystic fibrosis. The primary focus should be on managing the child's medical condition and providing appropriate care rather than discussing education settings.

Choice B rationale:

"Do not include your child when making decisions about treatment" is not appropriate advice. Involving the child in age-appropriate discussions about their treatment and healthcare decisions can empower them and promote their understanding and cooperation with the treatment plan. It is essential to engage children in their care to the extent possible, with guidance from healthcare providers.

Choice C rationale:

"Have your child wear a medical identification wristband" is the correct choice. Children with cystic fibrosis may have specific medical needs or allergies that emergency responders need to be aware of in case of emergencies. A medical identification wristband can provide crucial information about the child's condition and help ensure that they receive appropriate care in emergencies.

Choice D rationale:

"Ensure that your child does not receive the influenza vaccine annually" is not the recommended advice. Children with cystic fibrosis are at higher risk of respiratory infections, and the annual influenza vaccine is generally recommended to help prevent such infections. However, specific medical recommendations may vary, so it's essential for the guardians to follow the guidance of their child's healthcare provider regarding vaccinations.

Answer is: A, B, and C.Respiratory rate, oxygen saturation level, and heart rate are the three findings that require immediate follow-up. These findings indicate that the client is experiencing respiratory distress and possible complications of pneumonia, such as sepsis and cardiac arrhythmia. The client needs prompt intervention to improve oxygenation, stabilize the heart rhythm, and treat the infection.

• Statement D is wrong because the chronic health condition of the client (Parkinson’s disease) is not an acute problem that needs immediate attention. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease.
• Statement E is wrong because the current level of consciousness of the client (alert and oriented to self) is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation.
• Statement F is wrong because the tremors of the client are likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures.

Normal ranges for the vital signs and arterial blood gas are as follows:

• Respiratory rate: 12 to 20 breaths per minute
• Oxygen saturation level: 95% to 100%
• Heart rate: 60 to 100 beats per minute
• Blood pressure: less than 120/80 mmHg
• Temperature: 36.5°C to 37.2°C
• Arterial blood gas: pH 7.35 to 7.45, PaO2 80 to 100 mmHg, PaCO2 35 to 45 mmHg, HCO3 22 to 26 mEq/L

Correct answer is: A, B, and C.

Choice A rationale: Respiratory rate is 28 breaths per minute and labored. This is above the normal range of 12 to 20 breaths per minute and indicates that the client is experiencing respiratory distress. Respiratory distress can lead to hypoxia, tissue damage, and organ failure. Therefore, this finding requires immediate follow-up to improve the client’s oxygenation and ventilation.

Choice B rationale: Oxygen saturation level is 88% on room air. This is below the normal range of 95% to 100% and indicates that the client is hypoxemic. Hypoxemia can result from pneumonia, which causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. Hypoxemia can also cause dysrhythmias, confusion, and cyanosis. Therefore, this finding requires immediate follow-up to administer supplemental oxygen and monitor the client’s response.

Choice C rationale: Heart rate is 110 beats per minute and irregular. This is above the normal range of 60 to 100 beats per minute and indicates that the client has tachycardia and atrial fibrillation. Tachycardia can result from hypoxia, fever, infection, dehydration, or anxiety. Atrial fibrillation is a type of cardiac arrhythmia that causes irregular and rapid contractions of the atria, reducing the cardiac output and increasing the risk of thromboembolism. Therefore, this finding requires immediate follow-up to identify and treat the underlying cause, stabilize the heart rhythm, and prevent complications.

Choice D rationale: Chronic health condition is Parkinson’s disease. This is not an acute problem that requires immediate follow-up. However, it is important to monitor the client’s tremors and medication regimen for Parkinson’s disease, as they can affect the client’s mobility, safety, and quality of life.

Choice E rationale: Current level of consciousness is alert and oriented to self. This is not abnormal or concerning. However, it is important to monitor the client’s mental status for any signs of confusion or agitation, as they can result from hypoxia, infection, or medication side effects.

Choice F rationale: Tremors are in both hands. This is likely related to the Parkinson’s disease and not to the pneumonia. However, it is important to assess the severity and frequency of the tremors and provide comfort measures, such as warm blankets, massage, or relaxation techniques.