A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A reason:

The statement “Dark urine” is not typically a manifestation of an allergic reaction to oxacillin. Dark urine can indicate other issues such as dehydration, liver problems, or the presence of blood, but it is not a common sign of an allergic reaction to antibiotics.

Choice B reason:

The statement “Diarrhea” is a common side effect of many antibiotics, including oxacillin, but it is not specifically indicative of an allergic reaction. Diarrhea can occur due to the disruption of normal gut flora by antibiotics, but it does not necessarily mean the patient is allergic to the medication.

Choice C reason:

The statement “Urticaria” (hives) is a classic sign of an allergic reaction. Urticaria presents as raised, itchy welts on the skin and is a common allergic response to medications, including oxacillin. This reaction occurs when the immune system releases histamines in response to the drug.

Choice D reason:

The statement “Fever” can be associated with both infections and allergic reactions, but it is not a definitive sign of an allergic reaction to oxacillin. Fever can occur due to the underlying infection being treated or as a side effect of the medication, but it is not as specific as urticaria for indicating an allergic response.

Choice A reason:

Saying “It doesn’t appear as though you are feeling anxious” is not an appropriate response. This statement invalidates the client’s feelings and can make them feel misunderstood or dismissed. It is important for the nurse to acknowledge the client’s report of anxiety and provide a supportive environment for them to express their concerns.

Choice B reason:

“Tell me what has been happening lately” is the most appropriate response. This open-ended question encourages the client to share more about their experiences and feelings, which can help the nurse understand the underlying causes of the anxiety. It also shows empathy and a willingness to listen, which are crucial in building a therapeutic relationship.

Choice C reason:

“I think you should see a therapist” might be a helpful suggestion, but it is not the best immediate response. While referring the client to a therapist can be part of the long-term management plan, the nurse should first listen to the client’s concerns and provide immediate support. Suggesting therapy right away might make the client feel like their concerns are being brushed off.

Choice D reason:

“Do you think your anxiety is worse than everyone else’s?” is not a helpful response. This question can come across as judgmental and may make the client feel defensive or invalidated. It is important for the nurse to focus on understanding the client’s individual experience rather than comparing it to others.