Exhibits

The nurse uses the Modified Caregiver Strain Index (MCIS) and determines that the daughter is under significant stress caused by the assumption of her mother's care. The nurse is planning to have a discussion with the daughter on decreasing the stress she is experiencing as a caregiver. Select the 3 statements that the nurse should include when discussing caregiver stress with the client's daughter.

A. anaphylaxis

The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.

B. arrhythmias

The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be

triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.

C. Cardiac arrest

The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.

D. Necrosis

Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.

E. Renal failure

Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.

F. Peripheral edema

Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.

A. Encouraging the client to participate in a team sport may be overwhelming and unrealistic given the client's current level of depression and lack of activity. Starting with smaller, more achievable goals is essential in the initial stages of treatment.

B. Helping the client develop a list of daily affirmations is a positive intervention for promoting self-esteem, but it may not address the immediate need for increasing activity levels or engagement in meaningful activities.

C. Assisting the client in identifying goals for the day is the most important intervention at this stage. Setting achievable daily goals can help the client regain a sense of purpose and motivation. These goals should be realistic and tailored to the client's current abilities and interests.

D. Scheduling the client for a group focusing on self-esteem is beneficial, but it may not directly address the client's need for increased activity and engagement in meaningful daily activities.
Goals related to self-esteem can be incorporated into the client's plan of care but should be part of a comprehensive approach to treatment.