A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?

A. Documenting urine color is essential after a transurethral resection of the prostate to monitor for bleeding and ensure that the bladder irrigation is effective in clearing out blood clots.
B. Monitoring for bladder spasms is important as they can indicate the presence of blood clots or other complications, and they can be very painful for the client.
C. Checking the drainage tubing for obstructions is crucial to maintain the patency of the catheter and ensure continuous irrigation. Obstructions can lead to complications such as bladder distention or increased bleeding.
D. Maintaining the client in a left side-lying position is not specifically required for continuous bladder irrigation and is not typically part of postoperative care for a client who had a transurethral resection of the prostate.
E. Using clean technique for intermittent irrigation is important to prevent infection. While sterile technique is ideal, clean technique can be used for the client's own catheter care at home or in settings where sterile technique is not feasible. However, in a clinical setting, sterile technique is usually preferred to minimize infection risk.

A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's

individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.

D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.