A client reports pain worsening in their right forearm, rating the pain as 7 on a scale of 0 to 10. The client also states their right hand is "tingly.”. The client is able to move their fingers.

The client is avoiding eye contact with staff and is more withdrawn.

The client's adult child is at the bedside.

The client appears drowsy and less alert, but is oriented to person, place, time, and situation.

The client's apical pulse is regular, and their lungs are clear to auscultation.

A report is given to the operating room nurse, and the client is en route to the surgical suite via gurney for repair of a right radial fracture.

Choice A rationale

Visual disturbances are a less common side effect of risperidone and are not typically considered a priority finding. While they can be a nuisance for the client, they do not pose an immediate threat to the client's life. Other side effects require more immediate attention and intervention from the healthcare provider.

Choice B rationale

Risperidone can cause cardiac side effects such as QT prolongation, which can lead to life-threatening arrhythmias like Torsades de pointes. An irregular pulse is a critical finding that could indicate an underlying cardiac issue and requires immediate evaluation. This is a priority finding for the nurse to report to the provider.

Choice C rationale

Constipation is a common side effect of risperidone due to its anticholinergic properties. While it can cause discomfort, it is not an immediate life-threatening condition. The nurse should address this by encouraging fluid and fiber intake and possibly discussing a stool softener with the provider, but it is not the highest priority.

Choice D rationale

Dry mouth is a common and relatively benign side effect of risperidone. While it can cause discomfort and increase the risk of dental caries, it is not an urgent or life-threatening condition. The nurse can advise the client on strategies to manage this symptom, such as using sugar-free candies or chewing gum. *.

Choice A rationale

Scant lochia rubra with a few small clots is a normal finding at 2 days postpartum. Lochia rubra, which is dark red discharge, is expected during the first 3-4 days. Scant bleeding and small clots are considered normal and indicate the uterine healing process is progressing appropriately. Excessive bleeding or large clots would be cause for concern.

Choice B rationale

Bilateral ankle edema is a common and expected finding at 2 days postpartum. This is due to the mobilization of fluid retained during pregnancy and the effects of gravity. While it should be monitored, it typically resolves on its own. The nurse should assess for other signs of a more serious condition, such as unilateral leg swelling, pain, or redness, which could indicate a deep vein thrombosis.

Choice C rationale

A urine output of 2,500 mL/day is within the expected range for a postpartum client. Diuresis is a normal physiological process during the first few days after birth, as the body eliminates the excess fluid volume accumulated during pregnancy. Urine output typically ranges from 2,000 to 3,000 mL/day, indicating adequate kidney function and fluid mobilization.

Choice D rationale

Deep-tendon reflexes of 4+ are a hyperreflexic finding that can indicate a neurological complication, such as preeclampsia. Normal deep-tendon reflexes are typically 1+ to 2+. Hyperreflexia is a sign of central nervous system irritability and can precede seizure activity, making it a critical finding that requires immediate reporting to the provider for further assessment and intervention. .