To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.

B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.

C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.

D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.

Rationale for Correct Choices:

• Anemia: The lab values indicate that the client’s hemoglobin and hematocrit are lower than normal, suggesting anemia. Anemia in this case is likely due to blood loss from the trauma, as the client has internal hemorrhaging, with blood noted in the peritoneum.
• Blood loss: The client’s abdominal trauma, with liver and spleen lacerations and blood in the peritoneum, is a clear indicator of significant internal bleeding. This blood loss is directly responsible for the anemia seen in the lab results.
• Hemodilution from intravenous fluids: The client is receiving IV fluids at a rate of 100 mL/hr, which can dilute the blood and artificially lower hematocrit and hemoglobin levels. This is a common effect when fluids are given in large amounts, as the fluid increases plasma volume without immediately increasing red blood cells.

Rationale for Incorrect Choices:

• Acidosis: Acidosis typically presents with changes in blood pH and respiratory or renal compensation, which is not indicated by the client's lab results or current status. There are no signs of metabolic or respiratory acidosis in the current clinical picture.
• Rh factor sensitization: Rh factor sensitization usually occurs during pregnancy when Rh-negative mothers develop antibodies against Rh-positive fetal blood cells. This is unrelated to the client’s trauma and lab findings, which focus on anemia.
• Hypovolemia: Hypovolemia is more directly related to the blood loss and the hemodilution effect from intravenous fluid administration, making it a contributing but less specific factor in the anemia diagnosis.
• Disseminated intravascular coagulation (DIC): DIC is characterized by widespread clotting followed by bleeding. There is no evidence of abnormal clotting or bleeding issues in the lab results or clinical presentation, such as abnormal coagulation studies.
• Pregnancy: Pregnancy is not applicable in this case as the client's history does not mention any signs or symptoms of pregnancy. Anemia in this patient is related to trauma-induced blood loss and subsequent hemodilution, not pregnancy-related causes.
• Clotting cascade: While it is relevant to conditions like DIC or bleeding disorders, it does not directly explain the client's low hemoglobin or hematocrit. The lab results are more consistent with blood loss and fluid resuscitation.
• Blood administration: There is no mention of the client receiving blood products. While blood transfusion might be needed given the blood loss, there is no current indication from the lab results that blood administration has occurred or is required at this point.
• Immune response: An immune response is typically seen in infections or allergic reactions. The client’s current clinical condition and lab results do not suggest an infection or immune response but rather trauma-related blood loss and fluid effects.
• Hypoventilation: Hypoventilation typically leads to respiratory acidosis or elevated CO2 levels, but the client is intubated and on mechanical ventilation, with no indication of respiratory distress or acidosis.
• Hypoxia: Although trauma patients may experience hypoxia, the client’s oxygen saturation is 100%, and there is no indication of respiratory distress or hypoxia in the lab results. The anemia is more related to blood loss rather than a lack of oxygen in the tissues.