A client asks a nurse how long a heat application should be left in place. Which response should the nurse make?

A client with dehydration will have increased heart rate and decreased blood pressure due to the loss of fluid volume and the compensatory mechanisms to maintain cardiac output.

Choice C is wrong because dehydration does not cause increased temperature, but rather decreased temperature due to reduced blood flow to the skin.

Choice D is wrong because dehydration causes hyperactive muscle responses, such as muscle cramps, twitching, and tetany.

Choice E is wrong because dehydration can cause altered mental status, such as confusion, lethargy, or coma. Normal ranges for heart rate are 60-100 beats per minute, blood pressure is 120/80 mm Hg, and temperature is 36.5-37.5°C (97.7-99.5°F).

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.