A nurse is caring for a toddler.
The nurse’s observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next?

Choice A rationale

Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they

are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.

Choice B rationale

Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.

Choice C rationale

Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.

Choice D rationale

Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.

Choice A rationale

Constipation is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice B rationale

Weight gain of 5 lb in 1 month could be a side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice C rationale

Insomnia is a potential side effect of aripiprazole, but it is not typically a serious concern that would require notifying the provider.

Choice D rationale

Muscle stiffness could be a sign of a serious side effect of aripiprazole known as extrapyramidal symptoms. This could include conditions such as dystonia, akathisia, and Parkinsonism. If a patient experiences muscle stiffness while taking aripiprazole, the healthcare provider should be notified.