The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago.
The healthcare provider prescribes a sepsis protocol to be initiated.
Which intervention is most important for the nurse to include in the plan of care?

Choice A rationale:

Leaving the client alone to give them space is not an appropriate intervention for a client with depression and a history of suicide attempts. Isolation can increase feelings of hopelessness and despair, potentially leading to self-harm or suicidal thoughts.

Choice B rationale:

Removing any potential means of self-harm from the client's environment is the most essential intervention in this scenario. It is crucial to ensure the client's safety by eliminating access to items or substances that could be used for self-harm, such as medications, sharp objects, or other dangerous items. This intervention helps reduce the immediate risk of harm.

Choice C rationale:

Encouraging the client to confront their feelings of hopelessness is important in the long term, as it can be part of therapeutic interventions. However, it should not be the immediate priority when the client is at risk of self-harm. Ensuring their safety is paramount.

Choice D rationale:

Telling the client that they should be grateful for what they have is not an appropriate intervention. It can be perceived as dismissive of their feelings and may worsen their sense of hopelessness and isolation.

The correct answer is c. Recommend using a breast shield.

Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.

Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.

Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.

Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.