The nurse is continuing to care for the child.

Exhibits

After reviewing the discharge instructions with the family, which of the following statements by a parent indicate an understanding of the teaching? For each statement by the parent, click to specify if the statement reflects an understanding or indicates a need for reinforcement of the discharge teaching.

Rationale for correct choices:

• Administer oxygen at 2 L/min via nasal cannula: The client's oxygen saturation has dropped to 92% on room air, indicating mild hypoxia. Supplemental oxygen should be administered to improve myocardial oxygenation and reduce ischemia while further interventions are being prepared.
• Administer sublingual nitroglycerin: Nitroglycerin is a first-line medication for chest pain caused by suspected myocardial ischemia. It promotes vasodilation, reduces myocardial oxygen demand, and provides symptom relief. Administering it promptly can help prevent further cardiac damage.

Rationale for incorrect choices:

• Request a prescription for an increase in statin medication: Although the client has hyperlipidemia, increasing the statin dose is not an immediate priority during an acute chest pain episode. Lipid management is important long-term but does not address the acute ischemic event.
• Prepare the client for cardiac catheterization: Cardiac catheterization may eventually be necessary, but it is not the nurse’s first action. The priority is to stabilize the client’s symptoms (oxygenation and pain) before preparing for any invasive diagnostic or therapeutic procedure.
• Check a STAT cardiac troponin: Troponin has already been obtained and is within normal limits at this point. While serial troponins may be needed later, immediate nursing priorities focus on symptom relief and oxygenation rather than repeating the test right away.
• Request a prescription for a beta-blocker: Beta-blockers may be used in the treatment of suspected myocardial infarction to reduce heart rate and myocardial oxygen demand. However, their initiation typically follows pain relief, oxygenation, and diagnostic confirmation, not as the first nursing action.

Rationale:

A. Self-mutilation: This behavior is more commonly associated with borderline personality disorder. Individuals with borderline traits may engage in self-harm as a means of emotional regulation or response to abandonment fears, not typical in antisocial personality disorder.

B. Social isolation: Clients with antisocial personality disorder are often socially manipulative and may actively engage with others for personal gain. They are typically not socially withdrawn but can be superficially charming and exploitative.

C. Paranoid ideation: Paranoia is more closely linked with paranoid or schizotypal personality disorders. While someone with antisocial traits may be suspicious if it serves their manipulative purposes, persistent paranoid ideation is not a defining feature.

D. Lack of empathy: A hallmark feature of antisocial personality disorder is a disregard for others' feelings, rights, and safety. These clients often exhibit a lack of remorse and empathy, making them prone to violating social norms and laws without guilt.