A nurse is planning care for a client who is at 36 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse plan to implement?

Rationale:

A. Initiate one-to-one observation for the client: One‑to‑one observation is essential for safety when a client expresses risk for self‑harm, but the nurse must first assess the content of the hallucinations to determine the immediacy and severity of the risk. Understanding what the voices are saying guides the urgency of interventions and the level of monitoring required.

B. Turn on soft music to distract the client from hearing voices: Distraction techniques can help clients manage hallucinations, but they are not appropriate as an initial action when the client is reporting commands related to self‑harm. The priority is to gather critical assessment data before attempting coping strategies that may not address imminent danger.

C. Ask the client what they are hearing: Assessing the content, tone, and intent of the hallucinations is the first priority because command hallucinations can pose significant danger. Asking directly helps the nurse determine whether the client has an immediate plan or intent to act, which guides safety precautions and necessary interventions.

D. Refer to the hallucination as if it were real: Reinforcing hallucinations can worsen the client’s disorientation and increase distress. The nurse should maintain therapeutic boundaries by acknowledging the client’s experience without validating the hallucination, while also performing an immediate assessment of the risk of self‑harm.

Rationale:

A. Omeprazole: Omeprazole is a proton pump inhibitor used to reduce gastric acid secretion and prevent gastrointestinal irritation, especially in clients taking NSAIDs. It does not interfere with tissue regeneration, collagen formation, or immune responses involved in wound healing. It does not raise concern for impaired postoperative recovery.

B. Prednisone: Prednisone is a corticosteroid that suppresses inflammation and decreases immune system activity, which can impair the normal healing process. It slows collagen synthesis, reduces fibroblast activity, and decreases the inflammatory response needed for effective tissue repair. Clients taking prednisone are at increased risk for delayed wound healing.

C. Digesin: Digesin is an enzyme-based digestive aid used to support gastrointestinal function and has no impact on tissue repair or immune function. It does not influence collagen production, vascularization, or cellular regeneration. Therefore, it does not contribute to postoperative wound healing complications.

D. Morphine: Morphine is an opioid analgesic used for postoperative pain management and does not interfere with the physiologic processes involved in wound healing. Adequate pain control may actually improve recovery by reducing stress responses, enhancing mobility, and promoting better respiratory effort. It does not delay wound tissue repair.