A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

A. Report the blood pressure reading to the charge nurse: While notifying the charge nurse is important, the nurse should first validate the high reading by rechecking the blood pressure. Acting on a single, unverified reading could lead to unnecessary interventions or missed opportunities for accurate assessment.

B. Administer an antihypertensive medication: Administering antihypertensive medication based solely on a report without rechecking the blood pressure could be unsafe. Verification ensures that treatment is based on accurate clinical data and prevents unnecessary medication administration.

C. Remeasure the client's blood pressure: The first action should always be to recheck an unusually high or abnormal vital sign reading to confirm its accuracy. Errors can occur during measurement, and accurate confirmation is critical before proceeding with further interventions in a client with chronic kidney failure.

D. Instruct the client to remain in bed: While keeping the client in bed can help prevent complications if severe hypertension is confirmed, it is not the priority action. Verifying the blood pressure reading must occur first to determine the appropriate course of action.

A. Recommend frequent hot baths: Hot baths can exacerbate symptoms in clients with multiple sclerosis by increasing fatigue and worsening muscle weakness due to a rise in core body temperature. Clients are usually advised to avoid overheating and use cooling strategies instead to manage their symptoms.

B. Encourage the client to restrict performing range-of-motion exercises: Range-of-motion exercises are important in maintaining joint flexibility, muscle strength, and overall mobility. Restricting these exercises could lead to increased stiffness, weakness, and decreased functional ability in clients with multiple sclerosis.

C. Monitor the client's ability to perform ADLs: Monitoring the client's ability to perform activities of daily living is essential because multiple sclerosis often leads to progressive physical limitations. Regular assessment helps in planning appropriate interventions, promoting independence, and adjusting care as the disease progresses.

D. Initiate contact precautions: Contact precautions are not necessary for clients with multiple sclerosis because it is not an infectious disease. Multiple sclerosis is an autoimmune, neurodegenerative condition that requires supportive care rather than infection control measures.