A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

_______

and

__________

indicate manifestations of borderline personality disorder.

• Temperature 35.3°C (95.5°F): Hypothermia following surgery is concerning because it may reflect poor perfusion, internal bleeding, or shock. Immediate warming measures and evaluation are necessary to prevent further deterioration.
• Blood pressure 90/60 mm Hg: The client’s blood pressure is lower than previous values and indicates potential hypovolemia or ongoing blood loss. Hypotension post-surgery must be urgently addressed to avoid progression to shock.
• Skin cool and moist to touch: Cool, moist skin is an early clinical sign of decreased tissue perfusion and shock. When found alongside hypotension and hypothermia, it suggests that circulatory compromise may already be developing.
• Moderate amount of sanguineous drainage noted on lower dressing: Moderate bleeding post-laparoscopic surgery is abnormal. This finding, in combination with hypotension and other signs of poor perfusion, strongly suggests possible internal bleeding requiring urgent provider notification.
• Hypoactive bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery due to anesthesia and reduced gut motility. They are not an immediate sign of a critical complication unless accompanied by abdominal distension or severe pain, they should however be monitored.
• Heart rate 60/min: A heart rate of 60/min is at the lower limit of normal. Although 60/min is still technically within normal range, the trend of decreasing heart rate from baseline 90 beats/min, especially in the setting of hypotension and signs of poor perfusion, is concerning. This decline may indicate worsening hemodynamic status and must be monitored closely for further deterioration..
• Pedal pulse +1 bilateral: Diminished pedal pulses (+1) indicate reduced peripheral circulation. In isolation, it may not be critical, but when combined with hypotension and cool skin, it becomes part of the overall picture suggesting decreased perfusion and should be monitored carefully.

A. Fidelity: Fidelity refers to the responsibility to maintain trust and uphold promises made to clients. While important, the core issue in this case is not about fulfilling prior commitments but rather about responding truthfully to a direct question from the adolescent regarding their medical condition.

B. Authority: Authority is the recognized power to make decisions or enforce obedience, typically within a professional or legal framework. In this situation, the ethical dilemma is not related to decision-making power but centers on the nurse's obligation to provide honest communication.

C. Justice: Justice emphasizes fairness and equitable treatment of all clients in healthcare settings. Although justice is critical to ethical practice, the specific challenge here involves answering truthfully when asked about a relapse, rather than issues of equitable treatment or distribution of care.

D. Veracity: Veracity demands honesty and transparency when communicating with clients about their health. When the adolescent directly questions the nurse about their medical status, veracity obligates the nurse to provide truthful and accurate information, respecting the client's right to know.