Patient data

Click to highlight the information that should inform the nurse about the client's mental health.

During the initial assessment, the nurse observes the client has poor hygiene and has dried food on his mouth with food stains on his clothing. He reports living his near job. He reports trouble sleeping. He reports smoking one-half pack of cigarettes a day. He denies pain. He denies thoughts of self-harm or thoughts of suicide.

Rationale for correct answers:

• Client states, "It's been hard to catch my breath.": This subjective report of dyspnea (shortness of breath) is a significant indicator of respiratory distress or cardiovascular compromise, especially given her oxygen saturation was only 83% on room air.
• Crackles are heard in the bases of bilateral lungs: Crackles (rales) typically indicate fluid in the alveolar spaces. In a patient with a history of MI and hypertension, this is a classic sign of pulmonary edema related to left-sided heart failure.
• Heart rate is 118 beats/minute with a regular rhythm: This is tachycardia (a heart rate over 100 bpm). The heart is likely overcompensating for low oxygen levels or decreased cardiac output.
• Bilateral peripheral pitting edema of 2+ is present in both legs: Pitting edema indicates systemic fluid volume overload, commonly associated with right-sided heart failure or the heart's inability to pump effectively.

Rationale for incorrect choices:

• Client is alert and oriented to person, place, time, and situation: This is a normal neurological finding (A&O x4), indicating that brain perfusion is currently adequate.
• S1 and S2 heart sounds noted: These are the "lub-dub" sounds of normal heart valve closure. Their presence is a baseline normal finding.
• Client denies pain: At 0125, the absence of pain is a stable finding (though follow-up became necessary at 0135 when she began reporting "heavy" chest pain).
• Reports voiding prior to coming to hospital: This indicates recent renal perfusion and bladder function, which is a normal historical detail.

A. Giving carbonated drinks is inappropriate after gastric bypass surgery. Carbonation can increase gas, bloating, and discomfort, and may stress the surgically altered stomach. Assessing hydration is important, but offering carbonated beverages is unsafe.

B. Assessing vital signs and reporting the finding to the healthcare provider immediately is the most appropriate action. Abdominal distention early after gastric bypass may indicate postoperative complications such as bowel obstruction, internal hernia, or ileus, which can become life-threatening if not addressed promptly. Vital signs help identify early signs of shock or sepsis, such as hypotension or tachycardia, guiding timely intervention.

C. Measuring the abdomen and reviewing dietary intake is part of routine postoperative care, but it does not address the urgency of possible surgical complications. Delaying provider notification could worsen outcomes.

D. While ambulation helps prevent gas formation in stable postoperative patients, encouraging walking without assessing for serious complications is unsafe in the presence of sudden abdominal distention.