A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.

Choice A reason: This is incorrect because a drop in heart rate from 74 to 68/min is not a manifestation that requires immediate reporting to the provider. A mild decrease in heart rate can be normal or due to other factors such as medication, sleep, or relaxation. It does not indicate a worsening of brain injury or increased intracranial pressure.

Choice B reason: This is the correct answer because a change in the Glasgow Coma Scale score from 14 to 10 is a manifestation that requires immediate reporting to the provider. The Glasgow Coma Scale is a tool that measures the level of consciousness based on eye-opening, verbal response, and motor responses. A score of 14 indicates mild impairment, while a score of 10 indicates moderate impairment. A decrease in score can indicate deterioration of neurological status and increased intracranial pressure, which can be life-threatening.

Choice C reason: This is incorrect because the headache is not a manifestation that requires immediate reporting to
the provider. Headache is a common symptom of mild TBI and can be managed with analgesics, rest, and hydration. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is severe, persistent, or accompanied by other signs such as vomiting, confusion, or seizures.

Choice D reason: This is incorrect because diplopia is not a manifestation that requires immediate reporting to
the provider. Diplopia means double vision and can be caused by damage to cranial nerves or eye muscles due to TBI. It can be treated with eye patches, glasses, or surgery. It does not indicate a worsening of brain injury or increased intracranial pressure unless it is associated with other symptoms such as blurred vision, loss of vision, or eye pain.