The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?

Choice A rationale

Canned chicken broth with barley is not the best choice for a patient with hypertension. Canned foods, including chicken broth, are often high in sodium, which can raise blood pressure.

Choice B rationale

Tomato juice and gluten-free crackers may seem like a healthy option, but tomato juice can be high in sodium. While gluten-free crackers can be part of a healthy diet, they don’t offer any specific benefits for controlling hypertension.

Choice C rationale

A plain baked sweet potato is an excellent choice for a patient with hypertension. Sweet potatoes are high in potassium, which can help lower blood pressure. They’re also a good source of fiber and are naturally low in sodium.

Choice D rationale

Dill pickles and black olives are both high in sodium, which can raise blood pressure. Therefore, they’re not a good choice for someone with hypertension.

Based on the provided information, the following aspects of the assessment require urgent attention:

• The client’s request for sleeping medication: This indicates that she is having trouble sleeping, which can affect her recovery.
• The client’s distressing thoughts and memories about the house collapsing: This could be a sign of post-traumatic stress disorder (PTSD), which requires immediate attention and possibly referral to a mental health professional.
• The client’s statement about being in a “funk”: This could indicate depression or another mental health issue, which should be addressed promptly.
• The client’s preference for a quieter area of the unit: The noise by the nurses’ station is disturbing her rest, which is crucial for her recovery. Efforts should be made to accommodate her request if possible.