A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes.

Hypertonicity is a sign of increased muscle tone and stiffness, which can indicate that the newborn is experiencing withdrawal from methadone exposure in utero. Methadone is an opioid medication that can cross the placenta and cause neonatal abstinence syndrome (NAS) in the newborn.

Choice A, acrocyanosis, is wrong because it is a normal finding in newborns.

Acrocyanosis is a bluish discoloration of the hands and feet due to immature peripheral circulation. It usually resolves within the first 24 to 48 hours of life.

Choice B, bradycardia, is wrong because it is not a typical sign of withdrawal.

Bradycardia is a slow heart rate, usually less than 100 beats per minute in newborns. It can be caused by hypoxia, hypothermia, hypoglycemia, or vagal stimulation.

Choice C, bulging fontanels, is wrong because it is a sign of increased intracranial pressure, not withdrawal. Bulging fontanels can be caused by meningitis, hydrocephalus, or hemorrhage.

Normal ranges for newborn vital signs are as follows:

• Heart rate: 120 to 160 beats per minute
• Respiratory rate: 30 to 60 breaths per minute
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood pressure: 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic

safety followed by the client’s pain.

The nurse should first address the client’s safety because it is the most basic and essential need according to Maslow’s hierarchy of needs. The client may be at risk of abuse or neglect from his adult child, as evidenced by the bruises, body odor, unclean clothes, low BMI, and submissive behavior. The nurse should assess the client for signs of physical or emotional abuse and report any suspicions to the appropriate authorities. The nurse should also provide a safe and supportive environment for the client and encourage him to express his feelings and concerns.

The nurse should then address the client’s pain because it is a physiological need that affects the client’s comfort and well-being. The client rates his pain as 8 on a 0 to 10 scale and is not moving his right arm. The nurse should assess the client’s arm for signs of injury, such as swelling, deformity, or bleeding. The nurse should also administer analgesics as prescribed and monitor the client’s response to pain relief. The nurse should also provide non-pharmacological interventions, such as ice packs, elevation, or distraction.

The other choices are less urgent than safety and pain. The client’s abrasions are superficial and do not pose a significant risk of infection or bleeding. The client’s hygiene is important but not a priority at this time. The client’s BMI indicates that he is underweight, but this is a chronic condition that requires long-term nutritional intervention. The client’s heart rate is slightly elevated but not alarming, and may be due to pain, anxiety, or dehydration.