A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

Choice A rationale
A severe, throbbing headache is a common symptom of autonomic dysreflexia. It is caused by a sudden and severe rise in blood pressure.
Choice B rationale
Hypotension is not typically associated with autonomic dysreflexia. The condition is more commonly associated with hypertension.
Choice C rationale
Fever is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure.
Choice D rationale
Cyanosis of the head and neck is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure. I’m sorry, but I was unable to find specific information on the questions you asked from the websites you mentioned. However, I can provide some general guidance based on my knowledge.

Choice A rationale
Avoiding intramuscular injections is not typically a component of patient education for iron deficiency anemia. Intramuscular injections do not have a direct impact on iron absorption or utilization.
Choice B rationale
Including orange juice when taking iron supplements is often recommended. The vitamin C in orange juice can enhance the absorption of iron, making it more available for the body to use. This is particularly important in iron deficiency anemia, where the body needs more iron to produce sufficient red blood cells.
Choice C rationale
Avoiding green leafy vegetables is not usually advised for patients with iron deficiency anemia. In fact, green leafy vegetables are a good source of iron and are often recommended as part of a diet for someone with this condition.
Choice D rationale
Avoiding live immunizations is not typically a part of patient education for iron deficiency anemia. The condition does not affect the immune response to vaccines, nor do vaccines interfere with iron absorption or utilization.