A client presents to the medical surgical unit.

Which of the following findings requires further action by the nurse? Select all that apply.

A) Clenched teeth:
Clenched teeth are often a sign of discomfort or pain, especially in a client who is undergoing an epidural for pain management. This physical response typically occurs when the pain is not well controlled, as the body subconsciously tenses muscles in an attempt to cope with the pain. A clenched jaw is a clear indicator that the client is experiencing unrelieved pain, despite treatment.

B) Constipation:
Constipation is a potential side effect of medications such as opioids, which may be prescribed to manage pain. However, constipation itself is not necessarily an immediate indicator of unrelieved pain. While it can occur due to pain medications, it doesn't directly correlate with the effectiveness of pain relief from a spinal epidural.

C) Difficulty swallowing:
Difficulty swallowing, or dysphagia, is not a typical indicator of unrelieved pain. This symptom could be related to other issues such as neurological complications, side effects of medications, or other conditions. It is not a specific or common sign of ongoing pain, particularly in the context of an epidural for herniated disc treatment.

D) Urinary retention:
Urinary retention can occur due to the use of an epidural, especially if the epidural is affecting the lower spinal regions that control bladder function. However, it is more likely a side effect of the epidural itself rather than a sign that pain is unrelieved. While urinary retention should be monitored, it doesn't indicate whether the client’s pain is well-managed or not.

A) Can you tell me about the stresses in your life?: While identifying stressors is important in understanding the context of the client’s feelings, the priority in the context of suicidal ideation is to assess the immediacy of danger to the client. Understanding the plan and means for suicide is the first step in evaluating the severity of the situation.

B) "Do you have a plan for harming yourself?": This is the priority question because it directly assesses the immediacy and seriousness of the client’s suicidal ideations. Knowing whether the client has a specific plan allows the nurse to determine the level of risk and take appropriate action, such as ensuring the client is safe and arranging for immediate intervention, including hospitalization if necessary.

C) Do you have someone to discuss your feelings with?: While social support is important, this question does not immediately address the severity of the suicidal ideation. If the client is at high risk, the nurse must first assess the immediate danger posed by the suicidal thoughts and actions before discussing coping strategies or support systems.

D) Has anyone in your family ever died by suicide?: Although a family history of suicide can increase risk, this question is secondary to directly assessing the client's current risk. The focus should first be on evaluating the client’s immediate safety, such as whether they have a plan and the means to harm themselves.