A nurse is assessing a client following an esophagogastroduodenoscopy.
Which of the following findings should the nurse report to the provider?

Choice A rationale:

Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.

Choice B rationale:

Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.

Choice C rationale:

Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.

Choice D rationale:

Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.

Choice A rationale:

Encouraging fluid intake of 2,500 mL/day is the correct choice for a client with a fever due to an infection. Adequate hydration is essential in managing fever as it helps to prevent dehydration, maintain electrolyte balance, and support the body's immune response. Increasing fluid intake, preferably water, can also aid in lowering body temperature and promoting overall comfort.

Choice B rationale:

Maintaining the environmental temperature at 16°C to 18°C (60°F to 65°F) is not an appropriate intervention for a client with a fever. While it's essential to keep the client comfortable, adjusting the room temperature within a specific range is not the primary intervention. Focus should be on managing the fever through hydration, antipyretic medications, and addressing the underlying infection.

Choice C rationale:

Immersing the client in cold water is not a recommended intervention for managing fever. Cold water immersion can lead to shock, vasoconstriction, and potentially worsen the condition. It is essential to use methods like tepid sponging or cooling blankets if necessary, but these interventions should be performed under healthcare provider guidance and monitoring.

Choice D rationale:

Assisting the client to ambulate is a general nursing care activity and does not specifically address the fever due to infection. While ambulation is encouraged for many patients to prevent complications related to immobility, it is not the primary intervention for managing fever. The focus should be on hydration and other appropriate measures to reduce fever.