A nurse is assessing a client who is postoperative following orthopedic surgery.
Which of the following findings should the nurse identify as an indication of paralytic ileus?

Based on the information provided, the nurse should consider the following client findings for further evaluation:

A. Weight: The client's weight loss of 5 pounds (2.26 kg) over the last week needs further evaluation as it could be indicative of an underlying health issue.

D. Travel history: The client's recent travel to South Africa and the presence of respiratory symptoms raises concerns about possible exposure to infectious diseases, including tuberculosis, which is more prevalent in certain regions. Further evaluation of the travel history is essential.

E. Sputum characteristics: The client's report of "blood-tinged sputum" is concerning and should be evaluated further to rule out potential serious respiratory conditions.

F. Temperature: The presence of a "low-grade fever" should be further evaluated to assess the possible infectious etiology of the client's symptoms.

G. Heart Rate: The heart rate should be assessed further as an elevated heart rate could indicate an underlying systemic infection or other health issues.

The following client findings do not necessarily indicate the need for further evaluation in this context:

B. Report of cough: The client's report of a cough is the primary reason for their presentation to the emergency department and will, of course, be further evaluated as part of the assessment.

C. Blood pressure: Though monitoring blood pressure is essential, the information provided does not indicate any specific concerns regarding the client's blood pressure at this point.

A comprehensive assessment and further evaluation are necessary to determine the underlying cause of the client's symptoms. The nurse should collaborate with other healthcare professionals to conduct appropriate diagnostic tests and investigations to establish a diagnosis and provide appropriate care.

A. Incorrect. Open discussion is important to address the changes and challenges resulting from the stroke. Avoiding discussions might hinder effective communication and problem-solving.

B. Incorrect. Socialization with extended relatives can provide valuable support during this transition and should not be decreased without reason.

C. Incorrect. Authoritative communication might not be suitable for all family dynamics.

Effective communication should be respectful and tailored to the specific needs and preferences of the individuals involved.

D. Correct. Implementing firm but flexible boundaries allows for a healthy balance between support and maintaining the client's independence and autonomy.