The nurse continues to assist in the care of the client.

2030: Medication Administration Record.

Day 5, 0700: Ziprasidone 20 mg IM left deltoid muscle. Paliperidone 6 mg PO.

Nurses' Notes.

2015: 2030: Client appears disheveled with matted hair and stained clothing. Attempting to get out of handcuffs. The client states, "I have to. get out of here. I hear the helicopters. They are coming to get me!” Client able to state name, but not date. They believe they are in. a laboratory, run by the doctors who have been prescribing their medications.

When asked about their medical history, they reply, "My name is Jamie, and you are the devil.”

2145: Reviewed police report: Client found attempting to break through a window at the clinic downtown. When approached,. client yelled and tried to hit the officer with the stick they were using. "Get away, I have to get the notes, they are trying to. poison me.” Client appears to be responding to internal stimuli but is less outwardly agitated.

Changed into hospital scrubs with encouragement.

Handcuffs removed by police and 1:1 sitter at. The nurse is collecting data from the client 5 days after admission.

For each finding, click to specify whether the finding indicates the client's condition has improved or declined.

Choice A rationale:

Soft bowel sounds at a rate of 1 per minute describe hypoactive bowel sounds, which indicate decreased motility. This choice does not describe hyperactive bowel sounds.

Choice B rationale:

High-pitched bowel sounds are characteristic of hyperactive bowel sounds. These sounds are associated with increased motility and can indicate conditions such as diarrhea or early bowel obstruction. This choice correctly describes hyperactive bowel sounds.

Choice C rationale:

The absence of bowel sounds after listening for 3 to 5 minutes is indicative of absent or hypoactive bowel sounds, not hyperactive bowel sounds.

Choice A rationale:

Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.

Choice B rationale:

The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.

Choice C rationale:

Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.

Choice D rationale:

A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.

Choice E rationale:

Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.

Choice F rationale:

Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.

Choice G rationale:

A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.