The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit.

The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier.

Which response should the nurse provide?

Choice A rationale:

Observing for signs of depression is the most important intervention for the nurse to include in the client's plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client's overall well-being and successful outcomes.

Choice B rationale:

Monitoring for urinary incontinence is not the top priority in this case. While it's important to assess and address urinary incontinence when necessary, it is not the most critical concern for a client undergoing gastroplasty. Depression and post-surgical complications related to weight management surgery take precedence.

Choice C rationale:

Providing a wide variety of meal choices is not the most important intervention at this stage. After gastroplasty, dietary choices are typically restricted, and the focus is on a controlled and healthy diet. The priority is addressing the psychological and emotional aspects of the client's care, as well as monitoring for surgical complications.

Choice D rationale:

Applying sequential compression stockings is not the most crucial intervention in this situation. While prophylaxis against deep vein thrombosis (DVT) is important, it is not the top priority compared to addressing potential depression and emotional well-being in a client who has struggled with weight management for years.

Choice A rationale:

The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.

Choice B rationale:

The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.

Choice C rationale:

The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.

Choice D rationale:

The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.

Choice E rationale:

The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.