A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements by the client indicates an understanding of the teaching?

Rationale:

A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.

B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.

C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.

D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.

Rationale:

A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.

B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.

C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.

D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.