The nurse reviews the nurse’s notes and flow chart to identify trends.

Click to specify the notations that require immediate follow up (more than one notation may be correct.)

Exhibit 1: Patient’s Medical History

• Height: 5 ft 6 in (168 cm)
• Weight: 140 lb (63.5 kg)
• Delivery: The patient was transferred to the postpartum unit 1 hour after delivery of a 9 lb 1 oz (4.1 kg) female.

Exhibit 2: Nurse’s Notes and Flow Sheet

The patient was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra was moderate with small clots, no foul odor noted. The fundus was firm at the umbilicus. The episiotomy edges were well approximated, with no redness, edema, drainage, or ecchymosis. There was no pain, redness, or swelling in the calves.

• Boggy fundus 1 cm above the umbilicus
• Fundus rotated to the right
• Voided 200 mL of clear yellow urine

Exhibit 3: Vital Signs

• Heart rate: 96 beats/minute
• Blood pressure: 90/62 mm Hg

Exhibit 4: Provider’s Prescriptions

• IV infusing at 125 mL/hr
• A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing.

Exhibit 5: Physical Examination Results

• Episiotomy: Intact with no redness
• Body System: Genital/Urinary and Circulatory

Choice A rationale

Clarifying reality with the client about delusional thoughts is not the most effective approach when dealing with a client with dementia who is experiencing agitation and delusional thoughts. The cognitive impairment associated with dementia may make it difficult for the client to understand or accept the clarification, which could lead to increased frustration and agitation.

Choice B rationale

Reducing the client’s interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and could potentially worsen the client’s agitation and delusions. It does not directly address the client’s emotional distress.

Choice C rationale

Awakening the client earlier for daily morning care may further disrupt the client’s sleep patterns and potentially worsen agitation. It does not address the underlying issue of delusional thoughts and the client’s emotional distress.

Choice D rationale

Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client’s focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.

Choice A rationale

Osteoarthritis is a joint disease in which the tissues in the joint, including the cartilage, break down over time. The degradation of joint cartilage is the primary pathological condition that leads to the symptoms of osteoarthritis, such as increased pain and stiffness.

Choice B rationale

A systemic inflammatory response is not the primary cause of osteoarthritis. While inflammation can occur in the affected joint, osteoarthritis is not a systemic inflammatory disease like rheumatoid arthritis.

Choice C rationale

An infectious process in the synovial fluid is not typically associated with osteoarthritis. Infections can lead to a different type of arthritis known as septic arthritis.

Choice D rationale

A decrease in bone mineral density is associated with osteoporosis, not osteoarthritis. In osteoarthritis, the issue is primarily with the degradation of cartilage, not a loss of bone density.