Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

Choice A is correct because a distended bladder can displace the uterus and prevent it from contracting properly, leading to increased bleeding and risk of infection. The nurse should check for a distended bladder and assist the client to empty it if needed.

Choice B is incorrect because reviewing the hemoglobin is not a priority action. The hemoglobin may not reflect the current blood loss and may be done later.

Choice C is incorrect because massaging the uterus is not necessary if it is firm. Massaging a firm uterus can cause overstimulation and pain.

Choice D is incorrect because increasing intravenous infusion is not a priority action. The client may not need additional fluids if the bleeding is moderate and the vital signs are stable.

Choice B is correct because sodium intake can be regulated by limiting canned foods in the diet. Canned foods often contain high amounts of sodium as a preservative, which can increase blood pressure and fluid retention. The nurse should advise the client to choose fresh or frozen foods instead of canned foods or rinse them before eating.

Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Salt substitutes are products that contain potassium chloride or other ingredients that mimic the taste of salt but have less or no sodium. The nurse should advise the client to use salt substitutes sparingly and check with their healthcare provider before using them if they have kidney problems or take certain medications.

Choice D is correct because weight management is promoted by taking daily walks for thirty minutes. Being overweight or obese can increase blood pressure and strain the heart and blood vessels. The nurse should advise the client to lose weight or maintain a healthy weight by engaging in regular physical activity and eating a balanced diet.

Choice F is correct because uncontrolled hypertension can lead to renal damage. High blood pressure can damage the blood vessels in the kidneys and impair their function, leading to chronic kidney disease or failure. The nurse should advise the client to monitor their blood pressure regularly and take prescribed medications as directed.

Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol can cause vasodilation, which lowers blood pressure temporarily, but also stimulates the sympathetic nervous system, which raises blood pressure over time. The nurse should advise the client to limit alcohol intake to no more than one drink per day for women and two drinks per day for men.

Choice E is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner, when blood pressure is usually lower and more stable. The nurse should advise the client to avoid taking blood pressure readings when they are stressed, anxious, or have just exercised or eaten.