An adult client receives a prescription for diphenhydramine 15 mL PO every 12 hours PRN for pruritus. The bottle is labeled, "Diphenhydramine 12.5 mg/5 mL." What is the total daily dose in mg that the client receives? (Enter numerical value only.)

Rationale for Correct Choice:

• Depression: The client has symptoms of depression, such as general malaise, fatigue, decreased appetite, withdrawal, flat affect, and poor hygiene. Additionally, the client reports a significant change in sleep patterns, with an inability to sleep at night. His alcohol consumption could also contribute to depressive symptoms.

Rationale for Incorrect Choices:

• Anxiety disorder: While anxiety can cause fatigue, disrupted sleep, and lack of energy, it typically also presents with heightened nervousness, restlessness, excessive worry, or physical symptoms like rapid heart rate, which are not reported here. The client's withdrawal and lack of energy are more consistent with depression.
• Hypothyroidism: Hypothyroidism can cause fatigue, weight gain, and poor appetite, but the client's low BMI (17.7 kg/m²) suggests that weight loss, rather than gain, is occurring. Additionally, the lack of other hypothyroid symptoms, like constipation or cold intolerance, makes hypothyroidism less likely than depression in this scenario.

Rationale for Correct Choices:

• Bowel obstruction: The client's symptoms are classic signs of a bowel obstruction. Additionally, the lab results showing elevated sodium (165 mEq/L), low potassium (3.2 mEq/L), and low bicarbonate (20 mEq/L) suggest an electrolyte imbalance often seen in bowel obstructions due to fluid loss and impaired bowel function.
• Insert nasogastric tube: A nasogastric tube is commonly used in bowel obstruction to decompress the stomach, relieve vomiting, and prevent aspiration. It helps reduce abdominal distention and allows for drainage of the stomach contents.
• Maintain NPO status: Maintaining NPO status is essential in bowel obstruction to prevent further complications such as aspiration, vomiting, or perforation. It also helps to prepare the client for possible surgery if needed and allows the bowel to rest.
• Signs and symptoms of sepsis: Given the possibility of bowel perforation or ischemia in a bowel obstruction, monitoring for signs and symptoms of sepsis is crucial. Fever, tachycardia, and hypotension could indicate the onset of systemic infection due to bowel perforation or necrosis.
• Strict intake and output: Monitoring strict intake and output is vital to assess for dehydration or fluid imbalance, which can occur due to vomiting, diarrhea, or poor oral intake in bowel obstructions. Accurate monitoring helps guide treatment and fluid resuscitation.

Rationale for Incorrect Choices:

• Pancreatitis: Pancreatitis presents with severe upper abdominal pain that may radiate to the back, nausea, vomiting, and sometimes jaundice. There are no signs like elevated lipase or amylase levels to suggest pancreatitis.
• Food poisoning: Food poisoning can cause nausea, vomiting, and diarrhea, but it usually has an acute onset and resolves within a short period (usually a day or two). This child's symptoms have persisted for two days, and there is no mention of fever or diarrhea.
• Ruptured gallbladder: A ruptured gallbladder would present with severe right upper quadrant pain, fever, and jaundice due to bile leakage or infection. There is no indication of right upper quadrant pain or jaundice in this child.

• Culture emesis: While culturing emesis may be useful in diagnosing foodborne illnesses or infection, it is not necessary in a case of bowel obstruction. The primary intervention in bowel obstruction is relieving the obstruction and monitoring for complications.
• Prep for immediate gallbladder removal: Cholecystectomy is not indicated in this case. The client’s symptoms are not characteristic of gallbladder issues like cholecystitis or gallstone complications. The focus should be on diagnosing and managing the bowel obstruction.
• Administer oxygen via face mask: Oxygen administration is typically indicated in cases of respiratory distress or shock. While this client is experiencing discomfort, she is not showing signs of hypoxia or severe circulatory issues. Spo2 is 97% indicating adequate saturation.

• Bilirubin levels: Bilirubin levels are typically monitored when jaundice or liver dysfunction is suspected. This client does not show signs of jaundice or liver disease, and her symptoms are more consistent with a bowel obstruction.
• Rebound tenderness: Rebound tenderness is useful in cases of peritonitis or bowel perforation. However, the absence of guarding and the fact that the child is not exhibiting acute peritonitis symptoms makes rebound tenderness less relevant.
• Arterial blood gas (ABG): ABG measurements are typically used to assess respiratory and metabolic function. While the electrolyte imbalances seen in this patient (e.g., low bicarbonate) could suggest mild acidosis, ABG testing is not immediately necessary unless the client shows signs of severe metabolic disturbance or shock.