Final answer:
When updating a plan of care, it's essential for nurses to evaluate whether each intervention is anticipated, nonessential, or contraindicated. Each option presented requires careful consideration of the patient's specific needs and the critical concerns of their health status. These decisions are guided by a review of the patient's history, current condition, critical events, and procedures to be undertaken.
Step-by-step explanation:
When updating a plan of care, nurses must consider the appropriateness of potential interventions based on the specific conditions and needs of the patient. This requires a clear understanding of whether an intervention is anticipated, nonessential, or contraindicated for the particular situation. Here's a brief analysis of the given interventions:
- A) Encourage the client to attend group therapy: This intervention is generally anticipated as it is often beneficial for mental health support and social interaction, unless specifically contraindicated for the patient's condition.
- B) Administer a sedative to manage anxiety: This may be anticipated if the patient is experiencing high levels of anxiety, but should be administered with caution, considering the patient's medical history and current medications.
- C) Restrict fluids to prevent fluid overload: Could be anticipated in conditions like heart failure or renal failure, but may be contraindicated if the patient requires hydration or has different health concerns.
- D) Monitor vital signs every 4 hours: This is an anticipated and essential nursing intervention for most hospitalized patients, to keep track of their health status and detect any changes early.
It's crucial for the nurse to review critical concerns such as the patient's identity, procedure, anticipated critical events, and the patient's current condition and history. This information dictates whether an intervention is helpful, unnecessary, or harmful to the patient.