A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions should the nurse include in the plan for delivery?

Rationale:

A. Skin cool to touch: Cool skin is more commonly associated with shock states or severe peripheral vasoconstriction, not with a hypertensive crisis. In hypertensive crisis, the client is more likely to have warm skin due to increased circulation from elevated blood pressure.

B. Jugular vein distention: While jugular vein distention can occur in right-sided heart failure or severe fluid overload, it is not a hallmark manifestation of hypertensive crisis. The acute issue in hypertensive crisis is extreme elevation in blood pressure with end-organ effects.

C. Headache: Severe headache is a common and classic symptom of hypertensive crisis due to sudden, extreme elevations in blood pressure causing increased ICP and cerebral vessel stress. It often signals an urgent need for BP control to prevent complications such as stroke.

D. Weak peripheral pulses: Weak pulses are more often associated with low cardiac output or severe arterial obstruction. In hypertensive crisis, peripheral pulses are typically bounding and strong because of the elevated systemic vascular resistance.

Rationale:

A. "I don't think you will benefit from reviewing your therapist's notes right now.": This statement dismisses the client’s request without addressing legal and policy guidelines regarding access to records. It also inappropriately assumes the client’s capacity to benefit from the information.

B. "Are you not happy with your treatment?": This redirects the conversation away from the request and implies dissatisfaction, which can create defensiveness. It does not provide the client with accurate information about their right to access medical records.

C. "Why are you interested in seeing your therapist's notes?": Asking “why” can sound confrontational and does not answer the client’s question. The focus should be on explaining what parts of the record can be shared, according to policy and law.

D. "We can provide a copy of your records, but the therapist's notes are not included.": Psychotherapy notes are excluded from standard medical record disclosures under HIPAA, as they are kept separate to protect sensitive details.