A nurse is caring for a client who has borderline personality disorder (BPD). As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client?

A. Using touch to calm the client during periods of anxiety: Clients with paranoid schizophrenia may have heightened sensitivity to touch and may interpret it as threatening or intrusive. Therefore, using touch to calm the client may exacerbate their anxiety rather than alleviate it.

B. Rotating staff assignments for this client: Consistency in staff assignments can help establish trust and rapport with clients with paranoid schizophrenia. Rotating staff may disrupt this continuity and potentially increase the client's paranoia and suspicion.

C. Checking the client's mouth after the client takes medication: Clients with paranoid schizophrenia may exhibit medication non-compliance due to distrust or suspicion of medications. Checking the client's mouth after medication administration ensures that the client has ingested the medication and helps prevent hoarding or hiding of medication.

D. Assigning assistive personnel to feed the client at mealtimes: Clients with paranoid schizophrenia may have difficulty trusting others, particularly with personal activities such as feeding. Assigning assistive personnel to feed the client may increase the client's paranoia and resistance to care. It's essential to promote the client's autonomy and independence while providing support as needed.

Answer:

below 90 beats per minute (bpm)

Rationale:

For infants, especially those receiving digoxin, the heart rate is a critical parameter to monitor due to the medication's potential to affect cardiac function.

The general guideline for withholding digoxin in infants is if the apical heart rate is below 90 beats per minute (bpm) in infants. Therefore, the nurse should withhold the dose if the infant's apical heart rate is less than 90 bpm.

It's important to note that specific institutional protocols may vary, so nurses should always adhere to the guidelines established by their facility. Additionally, if the infant's heart rate is below the threshold, the nurse should promptly notify the healthcare provider for further evaluation and guidance.