A nurse is teaching a client who is to begin chemotherapy about a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include in the teaching?

Rationale:

A. Renal failure: The client has elevated creatinine levels (1.7 mg/dL), which suggests kidney impairment. This could be due to dehydration and osmotic diuresis associated with hyperglycemia, which is commonly seen in diabetic ketoacidosis (DKA) or hyperglycemic-hyperosmolar state (HHS).

B. Hypotension: The client’s blood pressure is low (96/65 mm Hg), which can be attributed to dehydration caused by excessive urination and hyperglycemia. Hypotension can worsen as the client becomes more dehydrated, potentially progressing to shock.

C. Cerebral edema: Cerebral edema is a rare but serious complication of diabetic ketoacidosis (DKA), particularly in younger patients and those with severe electrolyte imbalances. The rapid correction of hyperglycemia can cause osmotic shifts that may lead to cerebral edema. The client’s altered fluid balance increases this risk.

D. Septic shock: Although the client has a history of bronchitis and pneumonia, there is no evidence of active sepsis at this time. Septic shock is characterized by signs of infection, such as fever and widespread infection leading to organ dysfunction. This client’s symptoms point more toward a metabolic complication rather than sepsis.

E. Respiratory alkalosis: Respiratory alkalosis occurs when there is excessive loss of carbon dioxide due to hyperventilation. In this client, there is no indication of Kussmaul respirations to suggest respiratory alkalosis. The client is more likely to develop metabolic acidosis due to the presence of ketones and a low pH (7.30).

F. Cardiac arrhythmias: Elevated potassium levels (5.5 mEq/L) and the potential for rapid fluctuations in electrolytes in a client with DKA or HHS can increase the risk of cardiac arrhythmias. Potassium imbalances hyperkalemia or hypokalemia, are closely linked to arrhythmias.

Rationale for Correct Choices:

• Meningitis: Meningitis is an infection of the meninges which presents with headache, fever, nuchal rigidity, and photophobia, all of which the client has. The additional symptoms of malaise and lethargy also suggest meningitis.
• Decrease environmental stimuli: Decreasing environmental stimuli is crucial in managing meningitis, particularly when the patient has photophobia and a headache. Minimizing light, noise, and other stressors will help reduce discomfort, especially in the early stages of the infection.
• Initiate neurological checks every 2 hr: Neurological checks every 2 hours are essential to monitor the client for signs of worsening intracranial pressure or neurological deterioration, allowing early identification of any changes in mental status, consciousness, or motor function, enabling timely interventions.
• Temperature: Fever is a hallmark sign of meningitis, and monitoring the temperature will guide treatment effectiveness. A persistent high fever could indicate that the infection is progressing or that the treatment is not sufficient.
• Lactate: Elevated lactate levels could suggest poor tissue perfusion or sepsis, which can develop as a complication of meningitis. Monitoring lactate is crucial to assess for systemic involvement, and higher lactate levels may prompt quicker intervention to prevent further complications such as shock.

Rationale for Incorrect Choices:

• Septic shock: Septic shock typically involves severe hypotension, organ failure, and marked deterioration in condition, which are not evident at this stage. The current presentation aligns more with meningitis.
• Hydrocephalus: Hydrocephalus, characterized by excess cerebrospinal fluid, often causes headaches and lethargy but does not typically present with fever, nuchal rigidity, or photophobia. These are specific signs of meningitis, making this diagnosis less likely.
• Migraine headache: While migraines can cause headaches, nausea, and photophobia, they do not typically result in fever or nuchal rigidity, which are common symptoms of meningitis. Additionally, the patient’s lethargy and malaise are inconsistent with migraines.
• Administer gabapentin: Gabapentin is primarily used for neuropathic pain or seizures, not for infections like meningitis. The patient’s symptoms suggest an infection, and the priority is to start antimicrobial therapy to address the underlying cause.
• Prepare the client for surgery: Surgery is not typically required in the immediate management of meningitis unless there is a complication like an abscess. The priority at this stage is diagnosing the infection and starting appropriate antimicrobial therapy, not surgery.
• Administer Sumatriptan: Sumatriptan is a medication for treating acute migraine headaches, which the patient does not appear to have. The client’s symptoms, including fever, nuchal rigidity, and photophobia, suggest an infectious process rather than a primary headache disorder.
• Vascular changes: Monitoring vascular changes is not a primary concern in meningitis unless the patient is showing signs of septic shock or severe sepsis. At this stage, the more immediate parameters to monitor are temperature and lactate levels, which can directly indicate the progression of infection or sepsis.
• Gait: Gait issues are not directly associated with meningitis unless there is significant neurological involvement. Gait would be more relevant to monitor in conditions like strokes or neurological disorders affecting motor coordination.