A nurse is preparing to administer nystatin oral suspension to an infant who has oral candidiasis. Which of the following actions should the nurs take?

Rationale:

A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.

B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.

C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.

D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.

Rationale:

• Heart rate: A heart rate of 118/min indicates tachycardia, which may be a compensatory response to hypovolemia or blood loss. Combined with low blood pressure and low hemoglobin/hematocrit, it raises concern for active gastrointestinal bleeding and hemodynamic instability.
• Stool results: A positive hemoccult test confirms gastrointestinal bleeding, especially when paired with the client’s report of dark, tarry stools (melena). This requires prompt evaluation and may indicate upper GI bleeding, such as from a peptic ulcer.
• Current medications: The client is taking high-dose ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), which can cause or worsen gastric ulcers and bleeding. Continued use should be stopped immediately and replaced with safer alternatives.
• WBC count: The WBC count is within the normal range and does not indicate an active infection or inflammatory process at this time. It does not require urgent follow-up compared to other findings.
• Hemoglobin and hematocrit: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting blood loss likely due to GI bleeding. These values warrant urgent follow-up and possible transfusion depending on symptoms and stability.
• Temperature: The client’s temperature of 37.5°C (99.5°F) is slightly elevated but within normal limits and not a priority concern. There are no signs of infection or fever that require immediate follow-up.
• Blood pressure: A BP of 90/50 mm Hg indicates hypotension, which is concerning in the context of GI bleeding and low hemoglobin. This may reflect hypovolemia and requires prompt fluid management and monitoring.
• Respiratory rate: A respiratory rate of 18/min is within normal limits and does not indicate respiratory distress. It does not require immediate follow-up in this context.