A nurse is educating a client about hemodialysis treatment.
The nurse should recognize that which client statement indicates the need for further education?

Axillary temp 102°F (38.9°C), client shivering – Declined
The client’s temperature has increased (from 38.2°C to 38.9°C) with shivering, indicating worsening fever possibly due to infection or disease progression. This suggests systemic deterioration.

· Client resting in recliner – Improved
The client remains seated calmly, suggesting improved comfort and reduced agitation compared to earlier reports of restlessness and sleeplessness.

· RR 12/min, regular – Improved
A drop from 18/min to a slower, regular respiratory rate can indicate reduced anxiety or pain, and better oxygenation or sedation effect.

· Client calm, not agitated – Improved
Previously reported as agitated and confused, the client is now calm, which indicates a response to pain management and supportive care.

· Grimaces with movement – No Change
Grimacing shows pain persists with movement, indicating that chronic or severe pain is still present despite medication.

· Respirations irregular with periods of apnea – Declined
This pattern suggests Cheyne-Stokes or end-of-life breathing changes, a significant clinical decline.

· Productive cough – No Change
The cough remains unchanged, indicating persistent airway secretions or pulmonary involvement.

· Oral mucous membranes dry – Declined
Dehydration or reduced intake continues or worsens, shown by dry mucosa, indicating physical decline.

· Coarse rhonchi bilaterally – Declined
Rhonchi worsening or spreading bilaterally suggests progression of respiratory congestion or infection.

· Crackles in bases – No Change
Basal crackles are still present, indicating fluid or infection in the lower lungs, with no improvement.

Choice A rationale

Phantom breast pain is a neuropathic pain phenomenon that can occur after mastectomy, characterized by sensations of pain, itching, or tingling in the removed breast. While distressing for the client, it is a common neurological sequela and not typically considered an acute surgical complication indicating immediate danger.

Choice B rationale

A combination of numbness and pain around the breast incision is expected post-mastectomy. Numbness results from nerve transection during surgery, while pain is an anticipated consequence of tissue injury and inflammation. These are normal postoperative sensations, managed with analgesia, and do not typically signify a complication.

Choice C rationale

Lymphedema, characterized by swelling in the arm on the same side as the mastectomy, indicates a complication. It results from impaired lymphatic drainage due to lymph node removal or damage during surgery. This can lead to chronic swelling, discomfort, and increased risk of infection, requiring immediate intervention to manage and prevent progression.

Choice D rationale

A wound dressing saturated with blood every two hours indicates excessive bleeding, which is a significant complication post-mastectomy. While some serosanguineous drainage is normal, continuous saturation suggests active hemorrhage or a hematoma, requiring immediate assessment and potential surgical intervention to control the bleeding.