A school nurse is planning an educational program about nutrition for adolescents. Which of the following statements should the nurse include?

Rationale:

• Deep tendon patellar reflex: The client’s patellar reflex decreased from 4+ on day 1 to 2+ on day 2, indicating reduced hyperreflexia. This suggests a positive response to antihypertensive and preeclampsia management, lowering the risk for complications such as eclampsia or seizures.

• Heart rate: The client’s heart rate increased slightly from 84/min on day 1 to 90/min on day 2, which falls within a normal physiologic range and does not indicate significant improvement or deterioration. This shows that cardiovascular status has remained relatively stable.

• Blood pressure: Blood pressure decreased from severely elevated readings (162/112 mm Hg and 166/110 mm Hg) to 152/90 mm Hg, reflecting a partial response to antihypertensive therapy. Although still above normal, the downward trend indicates some improvement in maternal hemodynamic status.

• Edema: The client continues to have +3 pitting edema in bilateral lower extremities, which has not improved since the previous day. Persistent edema suggests that fluid balance and vascular permeability issues related to preeclampsia remain a concern and require ongoing monitoring.

A. A client who has depression and anxiety with an established plan of care: A medical-surgical nurse can safely care for a client with stable mental health conditions when a clear, established plan of care is in place. This client does not require constant psychiatric interventions, making it appropriate for assignment.

B. A client who is trying to engage in self-harm and does not understand why they cannot leave the facility: This client is high-risk and requires a nurse with specialized mental health training to implement safety measures and therapeutic interventions. Assigning this client to a medical-surgical nurse could compromise safety.

C. A client who is being discharged and needs information on substance abuse counseling: Discharge teaching and counseling for substance abuse require specialized knowledge and therapeutic communication skills typical of mental health nurses. A medical-surgical nurse may not have the expertise to provide adequate education and support.

D. A client who has been placed in restraints and requires documentation every 15 min: Clients in restraints require frequent monitoring, crisis intervention, and mental health expertise. This high-acuity situation is not appropriate for a nurse without psychiatric training.