The nurse should recognize which response is the immune system's reaction to a source of inflammation?

A. Auscultate for bowel sounds. While monitoring for postoperative ileus is important, it is not the priority intervention in a patient who is suddenly confused and lethargic after hip surgery. Avascular complications, fat embolism, or deep vein thrombosis (DVT) are more immediate concerns.
B. Compare pedal pulses bilaterally. A sudden change in mental status after hip arthroplasty could indicate a fat embolism or deep vein thrombosis (DVT) leading to pulmonary embolism. Comparing bilateral pedal pulses helps assess for signs of vascular impairment or embolic complications, which are serious postoperative risks. Fat embolism syndrome (FES) can cause confusion, lethargy, and respiratory distress, requiring immediate intervention.
C. Observe the surgical incision. While assessing for infection or bleeding is important, these complications do not typically cause sudden confusion and lethargy. Systemic embolic events or impaired circulation are more critical to assess first.
D. Assess mobility of the right leg. Evaluating mobility is part of routine post-arthroplasty care, but it does not directly address the sudden mental status changes seen in this patient. Assessing circulation and embolic risk takes priority.

A. Continues to take a prescribed vitamin D supplement. Vitamin D supplementation is recommended for older adults to support bone health and calcium absorption. This does not require additional follow-up.
B. Usually eats an additional serving of protein-rich foods daily. Adequate protein intake is essential for muscle maintenance and overall health in older adults. This is a positive nutritional habit and does not indicate a concern.
C. Takes 1200 mg of an over-the-counter calcium supplement daily. This is within the recommended daily intake for older adults (1,000-1,200 mg/day) to maintain bone health. Excess calcium intake should be monitored, but this amount alone does not require urgent follow-up.
D. Ate approximately 1,200 calories daily for the past two weeks. Older adults typically need at least 1,500-2,000 calories per day, depending on activity level and health conditions. A prolonged intake of only 1,200 calories per day may indicate malnutrition, unintentional weight loss, or inadequate nutrient intake, requiring further evaluation.