Exhibits

Click to highlight the findings that indicate the client is stable for discharge.

The client has rested well throughout the night with a continuous positive airway pressure (CPAP) device in place. Sequential devices are in place for venous thromboembolism prevention. The client ambulated 100 yards (91 meters) last night and 200 yards (183 meters) this morning.

She reports pain rating of 2 on 0 to 10 scale, located in the abdomen, described as aching. She has tolerated fluids throughout the night with no nausea or vomiting.

Assessment

Neurological Alert and oriented times 4. Cardiovascular WNL

Respiratory WNL

Gastrointestinal/Genitourinary Voided twice throughout night

A. Monitoring for changes in stool color is important because itraconazole can rarely cause liver toxicity, which may manifest as changes in stool color (e.g., clay-colored stools). This statement demonstrates the client's understanding of the need for monitoring for potential adverse effects.
B. Taking itraconazole with antacids is incorrect because antacids can reduce the absorption of itraconazole. This statement requires correction by the nurse as it could potentially decrease the effectiveness of the medication.
C. Drinking grapefruit juice can increase the effects of itraconazole by inhibiting its metabolism, leading to higher blood levels of the medication. Therefore, this statement is incorrect and requires correction.
D. Reporting any difficulty with breathing is important as itraconazole can rarely cause severe allergic reactions or respiratory side effects. This statement demonstrates the client's
understanding of the need to report any concerning symptoms.

Choice A Rationale: This response acknowledges the parent's feelings and offers empathy without judgment. It opens the door for further conversation and support, which is crucial in a healthcare setting where emotional support is part of holistic care.

Choice B Rationale: While this statement aims to provide hope, it is misleading because a full recovery is not guaranteed with surgery for myelomeningocele. It fails to address the parent's emotional state and the complexity of the condition.

Choice C Rationale: This question could make the parent feel more guilty by suggesting there might be a reason for self-blame. It does not provide the comfort or support the parent needs at this moment.

Choice D Rationale: Although this statement is meant to reassure the parent, it does not acknowledge the parent's current emotional distress. It also closes off the opportunity for discussing feelings and concerns further.