The nurse plans care for a client with a traumatic brain injury who exhibits signs of post-concussion syndrome, including headaches, irritability, and sleep disturbances.
Which strategy should the nurse include in the client's care plan?

Post-paracentesis complications require understanding fluid dynamics and infection risks. Rapid removal of ascitic fluid can cause massive fluid shifts, leading to circulatory collapse. Knowledge of sterile technique and hemodynamics is essential to differentiate between hypovolemia and peritonitis following the procedure.

Choice A rationale

Fluid overload would typically manifest as hypertension, neck vein distention, and crackles in the lungs. Tachycardia and hypotension are classic signs of volume depletion rather than an excess of fluid within the intravascular space following paracentesis.

Choice B rationale

While cardiac issues can cause hypotension, the specific context of post-paracentesis points toward volume shifts. Cardiac decompensation often involves fluid backup and pulmonary congestion, which does not align with the sudden loss of high volume peritoneal fluid.

Choice C rationale

Rapid removal of large volumes of ascitic fluid (often > 5 liters) causes shift from the intravascular space to the interstitium. This leads to decreased circulating volume, manifesting as tachycardia and hypotension (systolic < 90 mm Hg).

Choice D rationale

Peritonitis is a risk when the peritoneal cavity is punctured. Clinical signs include fever (normal range 36.5 to 37.5 degrees Celsius), abdominal pain, and tachycardia. Fever in this client suggests a potential inflammatory or infectious process.

Choice E rationale

Anxiety can cause tachycardia, but it rarely causes significant hypotension and fever. The nurse must prioritize physiological causes like fluid shifts or infection over psychological distress when vital signs are significantly altered after an invasive procedure.

Reporting suspected child abuse involves legal and ethical obligations of healthcare professionals. Knowledge of mandatory reporting laws, professional responsibility, and communication techniques for maintaining a professional boundary while disclosing required actions to concerned or upset parents is essential for this response.

Choice A rationale

Nurses are mandated reporters under the law. Stating this legal requirement provides a factual, non-judgmental explanation for the action. It frames the report as a professional obligation rather than a personal accusation against the upset parents.

Choice B rationale

Referring only to hospital policy is insufficient and potentially misleading. While policies exist, the primary driver for reporting suspected abuse is state law. This response lacks the necessary emphasis on the broader legal and ethical mandates of nursing.

Choice C rationale

This statement is subjective and accusatory, which can escalate a volatile situation. Nurses are required to report suspicion rather than provide a definitive belief of guilt. This phrasing undermines the objective nature of the mandatory reporting process.

Choice D rationale

Deflecting the concern to the provider is inappropriate because the nurse has an independent legal responsibility to report. Avoiding the parents question does not address the nurses role or the legal necessity of the report that was filed.