A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Rationales for Correct Findings:

• Client lying in the fetal position; This position often indicates severe abdominal pain and discomfort, signaling peritoneal irritation or acute abdomen. It helps reduce tension on the abdominal muscles, which suggests significant underlying pathology such as peritonitis or perforation.
• Abdominal pain rated 10 radiating to right shoulder: Shoulder pain, especially the right side, can be referred pain from diaphragmatic irritation caused by blood or gastric contents in the peritoneal cavity. This suggests a perforated ulcer or ruptured viscus, making it an alarming symptom requiring immediate attention.
• Abdomen distended and rigid: Abdominal rigidity and distension are classic signs of peritonitis, which may result from gastrointestinal perforation or severe intra-abdominal infection. This indicates an emergency, as the patient may require surgery to address the underlying cause.
• Vomited moderate amount bright red emesis: Bright red emesis indicates active upper gastrointestinal bleeding, which can lead to hypovolemia and shock. This finding requires prompt stabilization and diagnostic evaluation to control bleeding and prevent further deterioration.
• Heart rate 120/min: Tachycardia is an early compensatory response to hypovolemia or pain and can be a sign of shock or sepsis. It indicates the body is under stress, and immediate monitoring and intervention are essential to prevent further cardiovascular compromise.
• Blood pressure 70/49 mm Hg: Hypotension with a low systolic pressure indicates significant circulatory compromise, likely from blood loss or septic shock. This requires urgent fluid resuscitation and advanced cardiac monitoring to prevent organ failure.

Rationale for Incorrect Findings:

• Temperature 36.5° C (97.7° F): The temperature is within normal limits, and the absence of fever does not rule out serious abdominal pathology. Fever may develop later in peritonitis or infection, so normal temperature should not delay intervention but does not require immediate follow-up alone.
• Respiratory rate 20/min: This respiratory rate is within normal to mildly elevated range and may reflect mild distress but is not critical at this time. Oxygen saturation is adequate, and the patient is breathing without significant difficulty, so no urgent intervention based solely on this is needed.
• SpO2 95% room air: Oxygen saturation at 95% on room air is borderline but generally acceptable in adults without respiratory disease. It does not indicate respiratory failure and is not the priority concern in this clinical scenario.

A. “It will take at least a week before this medication reaches a therapeutic level.” Lithium reaches therapeutic plasma levels in approximately 5–7 days. Clients should be informed that mood stabilization and symptom improvement may not be immediate and may take up to 2–3 weeks.
B. “You will be placed on a low-sodium diet while taking this medication.” This is contraindicated because low sodium intake can increase lithium reabsorption by the kidneys, significantly raising the risk of lithium toxicity. A stable and adequate sodium intake is essential.
C. “This medication can cause weight gain” Weight gain is a common side effect of lithium, often related to changes in metabolism, appetite increase, and fluid retention. Clients should be monitored and provided with dietary and activity guidance.
D. “Blurred vision is an expected adverse effect of this medication.” Blurred vision is not an expected effect of lithium and may indicate toxicity or another medical condition. Any visual changes should prompt immediate evaluation rather than be considered routine.
E. “This medication can cause nausea and drowsiness.” These are common early side effects of lithium, especially during initiation. Taking the medication with food and adjusting administration times may help reduce gastrointestinal upset and sedation.