Exhibits

A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Rationale:

A. Oliguria: Clients with end-stage kidney disease (ESKD) often experience oliguria or significantly reduced urine output due to severe loss of nephron function. This contributes to fluid retention, electrolyte imbalances, and accumulation of waste products in the body.

B. Hypotension: ESKD more commonly leads to hypertension rather than hypotension because of fluid overload and activation of the renin-angiotensin-aldosterone system. Hypotension may occur only during dialysis or with certain medications but is not an expected finding in untreated ESKD.

C. Edema: Fluid retention caused by decreased glomerular filtration and impaired renal excretion leads to peripheral and sometimes generalized edema. Edema is a classic sign of ESKD and indicates compromised fluid balance.

D. Anemia: Impaired kidney function reduces erythropoietin production, leading to decreased red blood cell synthesis and resultant anemia. Clients often require erythropoiesis-stimulating agents or supplemental iron to manage this complication.

E. Bradypnea: Respiratory rate is not typically decreased in ESKD. If present, bradypnea would suggest a separate neurologic or respiratory issue rather than a direct effect of kidney failure. Clients may develop Kussmaul respirations if metabolic acidosis is severe, but bradypnea is not expected.

Rationale:

A. Suction the client every 2 hr: Frequent suctioning can increase intracranial pressure due to stimulation of the airway and coughing reflex. Suctioning should be performed only when necessary and with careful monitoring of ICP, rather than routinely every 2 hours.

B. Maintain ICP at 20 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. An ICP of 20 mm Hg or higher indicates increased intracranial pressure and requires intervention. Planning to maintain ICP at this elevated level is unsafe and not appropriate for care planning.

C. Avoid overstimulation of the client: Minimizing noise, unnecessary procedures, and environmental stimuli helps prevent spikes in ICP. Overstimulation can increase cerebral metabolic demand and worsen intracranial hypertension, so this intervention supports ICP management and neurologic stability.

D. Keep the client in a supine position: Supine positioning can impair venous drainage from the brain, potentially increasing ICP. Elevating the head of the bed to 30 degrees while maintaining spinal precautions is preferred to promote venous outflow and reduce intracranial pressure.