Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

A) Incorrect- Furosemide is a loop diuretic used to treat conditions such as edema and hypertension. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
B) Incorrect- Low-dose aspirin is often used for its antiplatelet effects to prevent cardiovascular events. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
C) Correct- Allopurinol is a medication used to treat gout by reducing the production of uric acid in the body. However, allopurinol can also increase the risk of forming calcium oxalate kidney stones, which is the type of kidney stone mentioned in the client's history. Calcium oxalate stones are the most common type of kidney stone, and they are composed primarily of calcium and oxalate. In this case, the client has a history of gout and is prescribed allopurinol. The nurse should bring the client's prescription for allopurinol to the healthcare provider's attention because

it has the potential to contribute to the formation of kidney stones, which could exacerbate the client's existing condition.
D) Incorrect- Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.

A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.