A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

Choice A rationale:

Repositioning the NG tube is not the appropriate action for hyperosmolar dehydration. This condition occurs due to an excessive concentration of solutes in the body, leading to a decrease in intracellular water. Repositioning the tube would not address the hyperosmolarity issue.

Choice B rationale:

Increasing the rate of formula delivery may exacerbate the problem by introducing more concentrated formula into the client's system, worsening hyperosmolarity. This choice can lead to further dehydration and electrolyte imbalances.

Choice C rationale:

Adding water to the formula is the correct action in this scenario. Hyperosmolar dehydration requires dilution of the concentrated formula to reduce the osmolarity. By adding water to the formula, the nurse can decrease the concentration of solutes, helping to rehydrate the client effectively.

Choice D rationale:

Switching to a lactose-free formula is not the appropriate intervention for hyperosmolar dehydration. The issue lies in the concentration of the formula, not in its lactose content. Adding water is the more suitable and direct approach to address the problem.

Choice A rationale:

The nurse should ensure that the side rails are up on the client's bed. This action is essential for the safety of the client with severe preeclampsia, as it prevents accidental falls or injuries. Preeclampsia is a hypertensive disorder of pregnancy characterized by high blood pressure and signs of organ damage, and it poses significant risks to both the mother and the fetus. By keeping the side rails up, the nurse can minimize the risk of falls and ensure the client's safety while in bed.

Choice B rationale:

Ambulating the client every 4 hours is not appropriate for a pregnant woman with severe preeclampsia. Preeclampsia can cause high blood pressure, swelling, and proteinuria. It is a serious condition that requires close monitoring and strict bed rest to prevent complications such as seizures or eclampsia. Ambulation may increase the risk of falls and is contraindicated in this situation.

Choice C rationale:

Checking the fetal heart rate twice daily is important in the care of a pregnant client with severe preeclampsia. However, ensuring the client's safety by keeping the side rails up on the bed takes priority. While monitoring the fetal heart rate is crucial for assessing the baby's well-being, it does not address the immediate safety concerns of the client, which can be addressed by maintaining the side rails up.

Choice D rationale:

Providing the client with a low-protein diet is not the correct action for a pregnant woman with severe preeclampsia. In fact, pregnant women with preeclampsia are often advised to increase their protein intake to help manage their condition. A low-protein diet can lead to malnutrition and may not provide the necessary nutrients for both the mother and the developing fetus. The primary focus should be on bed rest, monitoring vital signs, and managing symptoms to prevent complications.