The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

Choice A rationale: While the healthcare provider manages prescriptions, the nurse's immediate priority is providing education to prevent non-compliance and relapse. Referring the client elsewhere may delay critical reinforcement of treatment goals.

Choice B rationale: Although many side effects eventually diminish, telling the client they will "most likely dissipate" offers no immediate solution to their dissatisfaction and may diminish the client's current physical discomfort.

Choice C rationale: While true that antidepressants require tapering to avoid withdrawal, this does not address the client's misconception that the medication is no longer needed because they feel improved.

Choice D rationale: Patients often mistake the therapeutic effect for a permanent "cure." Explaining that they feel better specifically because the medication is working helps them understand the necessity of continued maintenance therapy.

Course breath sounds - Respiratory Distress

Decreased level of consciousness - Cerebral Edema

Seizure activity - Cerebral Edema

Irritability - Both (Can be associated with both cerebral edema and respiratory distress)

Bradycardia - Cerebral Edema

Rationale:

Course breath sounds - Respiratory Distress

Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.

Decreased level of consciousness - Cerebral Edema

A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.

Seizure activity - Cerebral Edema

Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.

Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.

Bradycardia - Cerebral Edema

Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.