Exhibits

The nurse is concerned about the client's temperature. Which interventions can the nurse use to address the client's temperature? Select all that apply.

A. Blood pressure. The nurse should assess the client’s blood pressure both while lying down and standing to check for any signs of orthostatic hypotension, which is a drop in blood pressure upon standing.

B. Apical heart rate. While heart rate is important, it is not directly related to the side effect of orthostatic hypotension.

C. Pulse pressure. Pulse pressure (the difference between systolic and diastolic blood pressure) is not the primary assessment when checking for orthostatic hypotension.

D. Level of consciousness. Although important for overall assessment, the primary focus for orthostatic hypotension is blood pressure.

A. Caregivers often feel obligated to keep promises, but emphasizing a promise made to the mother may create more pressure. The nurse should instead encourage realistic expectations and flexibility in caregiving.
B. Moving a parent to a care facility does not reflect a lack of love. This statement might create guilt in the caregiver. The nurse should support the caregiver in considering all options without judgment.
C. Comparing caregiving to raising a child is unrealistic. The needs of elderly parents with complex health conditions are different from those of children. This comparison may add unnecessary pressure on the caregiver.
D. Caregiver stress can be overwhelming, and it's important for caregivers to prioritize self-care. Taking time for themselves and nurturing other relationships can help reduce burnout and maintain emotional well-being.
E. Involving the client in decision-making respects her autonomy, empowers her, and may reduce feelings of helplessness. It also provides the daughter with an opportunity to share responsibility for care, which can lessen her burden.
F. Caregivers can experience a range of emotions, including frustration, anger, or exhaustion. It is essential to allow the caregiver to acknowledge these feelings, but saying it’s "okay" to not like the person being cared for can create guilt and confusion. Instead, the nurse should normalize the range of emotions caregivers feel and provide emotional support.
G. Saying "no" is not selfish; it's necessary for maintaining a healthy balance. Encouraging caregivers to set boundaries is vital to prevent burnout.
H. Focusing on negative situations that may arise can increase anxiety and stress for the caregiver. Encouraging the daughter to focus on the present and practical steps can reduce unnecessary worry and help her manage her responsibilities more effectively.