A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.

Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.

Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.

Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.

Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.

A. "I had to retire because my boss didn't like me.": Indicates projection, attributing personal feelings to someone else.

B. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Indicates positive coping, not compensation.

C. "I'm so glad I've retired because the work was making me sick and depressed.": Indicates rationalization, justifying the situation.

D. "Since I retired, I have entered many gardening competitions.": The client is compensating for the loss of work-related identity by engaging in competitive gardening, a constructive coping strategy.