The nurse is caring for a client with chronic kidney disease (CKD). Which meal selection should the nurse recommend to the client?

Rationale for Correct Choices:

• Bowel obstruction: The client's symptoms are classic signs of a bowel obstruction. Additionally, the lab results showing elevated sodium (165 mEq/L), low potassium (3.2 mEq/L), and low bicarbonate (20 mEq/L) suggest an electrolyte imbalance often seen in bowel obstructions due to fluid loss and impaired bowel function.
• Insert nasogastric tube: A nasogastric tube is commonly used in bowel obstruction to decompress the stomach, relieve vomiting, and prevent aspiration. It helps reduce abdominal distention and allows for drainage of the stomach contents.
• Maintain NPO status: Maintaining NPO status is essential in bowel obstruction to prevent further complications such as aspiration, vomiting, or perforation. It also helps to prepare the client for possible surgery if needed and allows the bowel to rest.
• Signs and symptoms of sepsis: Given the possibility of bowel perforation or ischemia in a bowel obstruction, monitoring for signs and symptoms of sepsis is crucial. Fever, tachycardia, and hypotension could indicate the onset of systemic infection due to bowel perforation or necrosis.
• Strict intake and output: Monitoring strict intake and output is vital to assess for dehydration or fluid imbalance, which can occur due to vomiting, diarrhea, or poor oral intake in bowel obstructions. Accurate monitoring helps guide treatment and fluid resuscitation.

Rationale for Incorrect Choices:

• Pancreatitis: Pancreatitis presents with severe upper abdominal pain that may radiate to the back, nausea, vomiting, and sometimes jaundice. There are no signs like elevated lipase or amylase levels to suggest pancreatitis.
• Food poisoning: Food poisoning can cause nausea, vomiting, and diarrhea, but it usually has an acute onset and resolves within a short period (usually a day or two). This child's symptoms have persisted for two days, and there is no mention of fever or diarrhea.
• Ruptured gallbladder: A ruptured gallbladder would present with severe right upper quadrant pain, fever, and jaundice due to bile leakage or infection. There is no indication of right upper quadrant pain or jaundice in this child.

• Culture emesis: While culturing emesis may be useful in diagnosing foodborne illnesses or infection, it is not necessary in a case of bowel obstruction. The primary intervention in bowel obstruction is relieving the obstruction and monitoring for complications.
• Prep for immediate gallbladder removal: Cholecystectomy is not indicated in this case. The client’s symptoms are not characteristic of gallbladder issues like cholecystitis or gallstone complications. The focus should be on diagnosing and managing the bowel obstruction.
• Administer oxygen via face mask: Oxygen administration is typically indicated in cases of respiratory distress or shock. While this client is experiencing discomfort, she is not showing signs of hypoxia or severe circulatory issues. Spo2 is 97% indicating adequate saturation.

• Bilirubin levels: Bilirubin levels are typically monitored when jaundice or liver dysfunction is suspected. This client does not show signs of jaundice or liver disease, and her symptoms are more consistent with a bowel obstruction.
• Rebound tenderness: Rebound tenderness is useful in cases of peritonitis or bowel perforation. However, the absence of guarding and the fact that the child is not exhibiting acute peritonitis symptoms makes rebound tenderness less relevant.
• Arterial blood gas (ABG): ABG measurements are typically used to assess respiratory and metabolic function. While the electrolyte imbalances seen in this patient (e.g., low bicarbonate) could suggest mild acidosis, ABG testing is not immediately necessary unless the client shows signs of severe metabolic disturbance or shock.

A. Encourage the client's family to visit more often: The client is withdrawn, increased visits may feel overwhelming. This approach assumes the client is ready for interaction, which may not be the case, and does not directly address communication barriers.

B. Encourage the client to participate in group activities: This may be premature for a client who is severely withdrawn. Pushing participation too soon may increase distress or resistance, making rapport-building through simpler interactions more effective initially.

C. Engage the client in non-threatening conversations: Starting with gentle, non-intrusive conversations helps build trust and re-establish communication. It meets the client where they are emotionally and lays a foundation for further therapeutic engagement without increasing anxiety or pressure.

D. Schedule a daily conference with the social worker: Daily meetings may not be feasible or welcomed by a withdrawn client. Interventions should first aim to re-establish connection through nurse-client interaction.