The nurse is collecting data from the client following the transfusion of 2 units of packed RBCs.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.

Laboratory Results:

1800:

WBC count 6,700/mm (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs:

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Temperature 37.5°  C (99.5°  F)

O2 saturation 100% 2 L/min O2 via nasal cannula

Assessment:

1800:

Physical Exam

General: no distress

Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding

Neurologic: awake and alert

A. "Our child has increased his daily caloric intake." Methylphenidate is a stimulant that commonly suppresses appetite, leading to decreased caloric intake and potential weight loss. An increase in appetite would not indicate medication effectiveness but might suggest the dose is too low or the medication is wearing off.
B. "Our child is able to complete his homework on time." Methylphenidate is used to improve attention, impulse control, and focus in children with ADHD. The ability to complete tasks, such as finishing homework on time, demonstrates improved concentration and executive functioning, which indicates the medication is working effectively.
C. "Our child has a better grasp of reality." ADHD is not primarily associated with a loss of reality testing, as seen in psychotic disorders. While methylphenidate improves focus and impulse control, it does not target symptoms such as delusions or hallucinations.
D. "Our child has lost some weight since his last appointment." Weight loss is a common side effect of methylphenidate due to appetite suppression. While this can be monitored, it does not indicate medication effectiveness in treating ADHD symptoms.

A. Recurring urinary tract infections. Chronic infections act as internal stressors because they arise from within the body, leading to physical discomfort and emotional strain. While they can contribute to stress, they do not originate from an external source, such as environmental or situational factors.
B. Report of feeling depressed. Depression is an internal emotional state rather than an external stressor. Although it can be triggered by external events, depression itself comes from psychological and physiological processes within the individual rather than from outside influences.
C. Lack of nutritional knowledge. Limited knowledge about nutrition is an internal factor affecting decision-making rather than an external stressor. External stressors involve changes in one's environment or circumstances that create pressure, whereas knowledge gaps influence behavior but do not directly impose stress from an outside source.
D. A recent move to a new city. Moving to a new city is an external stressor as it involves environmental change, social adaptation, and logistical challenges. Adjusting to a new home, job, or social network can be overwhelming, increasing stress levels due to uncertainty, unfamiliar surroundings, and the need for adjustment.