A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Rationale:

A. Assist the client to ambulate: Ambulation is encouraged after a laparoscopic cholecystectomy to stimulate peristalsis and help relieve abdominal distention caused by retained gas from insufflation during the procedure. It promotes bowel movement and absorption of gas, improving comfort.

B. Prepare the client for a paracentesis: Paracentesis is used to remove fluid from the peritoneal cavity, typically in clients with ascites or severe fluid retention. Abdominal distention after this procedure is usually due to gas, not fluid.

C. Insert a rectal suppository: Suppositories may stimulate bowel movements but are not the first-line intervention for post-laparoscopic gas-related distention. Encouraging natural movement through ambulation is more effective and less invasive initially.

D. Place the client in the prone position: The prone position is not typically used for relieving abdominal distention. It may cause discomfort and does not aid in gas movement through the intestines as effectively as upright or walking positions.

Rationale:

• Client has initiated a daily exercise routine: This indicates self-motivation, structured routine, and engagement in positive coping behaviors, all of which are therapeutic goals in managing schizophrenia.
• Client utilizes deep breathing techniques as needed: Use of self-regulation techniques like deep breathing suggests the client is managing anxiety and stress proactively.
• Client has joined a local support group: Participation in social support groups improves social functioning and decreases isolation, a common issue in schizophrenia.
• Client has been reading books about their illness: Demonstrates insight, knowledge-seeking behavior, and a willingness to understand and manage the condition, which aligns with psychoeducation goals.
• Client participates in cognitive-behavioral therapy sessions with their mental health provider: Engagement in CBT is a strong indicator of therapeutic alliance and compliance with structured treatment plans aimed at cognitive restructuring and behavioral management.

Rationale for Incorrect Finding:

• Client reports spending most of their time alone in their apartment: Although some solitude is not unusual, spending most of the time alone may indicate ongoing social withdrawal, a negative symptom of schizophrenia, and a barrier to full community reintegration.
• Client reports drinking 4 to 5 cups of coffee each morning: Excessive caffeine can worsen anxiety, interfere with sleep, and interact with psychiatric medications, so this behavior does not align with optimal treatment outcomes.