A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?

A. Encourage regular turning:
While turning is important for preventing complications like pressure ulcers, in this acute situation, addressing fluid imbalance and potential sepsis take precedence.

B. Monitor skin for breakdown:
Monitoring for skin breakdown is essential but is not the most critical intervention at this moment.

C. Assess wound drainage daily:
Daily assessment of wound drainage is important for evaluating the status of the surgical site. However, in this situation of potential anastomosis leakage with signs of systemic infection and hypotension, immediate interventions to stabilize the client's condition are of higher priority.

D. Strict IV fluid replacement:
This is the correct answer. The client is displaying signs of systemic infection (fever) and possible sepsis (tachycardia, hypotension), which might be due to an anastomosis leakage following gastric bypass surgery. Ensuring adequate IV fluid replacement is crucial to address hypotension, maintain perfusion, and support hemodynamic stability in this critical situation.

A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.

B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.

C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.

D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.