A nurse is developing a care plan for a client who has schizophrenia and is taking chlorpromazine. Which of the following actions should the nurse include in the plan?

 

The correct answer is: The nurse has reviewed the client’s medical record. The client is at risk for developing

Hypotension and Metabolic Acidosis

Choice A: Hyperkalemia

Hyperkalemia refers to an elevated level of potassium in the blood. The normal range for potassium is 3.5 to 5.0 mEq/L. In this case, the client’s potassium level is 5.0 mEq/L, which is at the upper limit of normal. While the client is not currently hyperkalemic, they are at risk due to their condition. However, hyperkalemia is not the most immediate concern based on the provided data. The client’s symptoms and diagnostic results point more directly to other conditions.

Choice B: Hypertension

Hypertension is high blood pressure. The client’s blood pressure is 96/68 mm Hg, which is below the normal range (typically around 120/80 mm Hg). This indicates hypotension rather than hypertension. Given the client’s history of hypertension, the current low blood pressure is concerning and suggests a different issue, such as dehydration or fluid loss from diarrhea.

Choice C: Hypokalemia

Hypokalemia is a condition where potassium levels are below normal. The client’s potassium level is 5.0 mEq/L, which is within the normal range. Therefore, hypokalemia is not a concern in this scenario. The client’s potassium level does not indicate a risk for hypokalemia, and their symptoms do not align with this condition.

Choice D: Hypernatremia

Hypernatremia is an elevated sodium level in the blood. The normal range for sodium is 136 to 145 mEq/L. The client’s sodium level is 149 mEq/L, which is above the normal range, indicating hypernatremia. This condition can result from dehydration, which is consistent with the client’s symptoms of diarrhea and poor skin turgor. However, while hypernatremia is a concern, it is not the most critical issue compared to hypotension and metabolic acidosis.

Choice E: Hypotension

Hypotension is low blood pressure. The client’s blood pressure is 96/68 mm Hg, which is below the normal range. This low blood pressure, combined with symptoms of weakness, dizziness, and poor skin turgor, suggests significant fluid loss and dehydration. Hypotension is a critical concern as it can lead to inadequate perfusion of organs and tissues, potentially causing further complications.

Choice F: Renal Failure

Renal failure refers to the kidneys’ inability to filter waste from the blood effectively. While the client’s urine output is low (30 mL/hr), which could indicate renal impairment, there is no direct evidence from the provided data to confirm renal failure. The client’s basic metabolic profile does not show elevated creatinine or BUN levels, which are typical indicators of renal function.

Choice G: Metabolic Acidosis

Metabolic acidosis is a condition where there is too much acid in the body fluids. The normal range for blood pH is 7.35 to 7.45. The client’s pH is 7.33, which is below the normal range, indicating acidosis. Additionally, the bicarbonate (HCO3) level is 19 mEq/L, which is below the normal range of 21 to 28 mEq/L. These findings confirm metabolic acidosis, likely due to the loss of bicarbonate through diarrhea.

Choice A reason: Testing new nurses for exposure to tuberculosis

Testing new nurses for exposure to tuberculosis is an example of secondary prevention. Secondary prevention aims to detect and treat diseases early, often before symptoms are present, to minimize serious consequences. This activity involves screening and early detection, which are hallmarks of secondary prevention.

Choice B reason: Providing treatment for clients who have chronic obstructive pulmonary disease

Providing treatment for clients who have chronic obstructive pulmonary disease (COPD) is an example of tertiary prevention. Tertiary prevention focuses on managing existing diseases to prevent complications, reduce disability, and improve quality of life. This includes ongoing treatment and rehabilitation efforts to manage chronic conditions effectively.

Choice C reason: Performing screening for sexually transmitted infections

Performing screening for sexually transmitted infections (STIs) is another example of secondary prevention. Screening programs aim to detect diseases early, often before symptoms appear, to provide timely treatment and prevent further spread. This activity is crucial for early intervention and control of infectious diseases.

Choice D reason: Administering influenza immunizations at a local health fair

Administering influenza immunizations is an example of primary prevention. Primary prevention aims to prevent diseases from occurring in the first place through measures such as vaccinations, health education, and lifestyle modifications. Immunizations are a key component of primary prevention strategies.