A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?

Rationale:

• Minimize environmental stimuli for the client: The client is displaying signs of acute mania including hyperactivity, distractibility, pressured speech, and hallucinations. A low-stimulation environment helps reduce sensory overload, agitation, and impulsive behavior, promoting safety and stabilization in manic patients.
• Weigh the client each day: The client has poor nutritional intake and increased activity, increasing risk for weight loss. Daily weights allow nurses to monitor nutritional status and detect early signs of dehydration or malnutrition, which are common in manic episodes where the client neglects eating.
• Provide the client with high-calorie fluids every hour: Due to constant movement, poor oral intake, and elevated energy levels, clients in a manic state are at high risk for fluid and calorie deficits. Offering high-calorie fluids frequently supports hydration and nutrition without requiring the client to sit down for full meals, which they may be too distracted to do.

• Encourage the client to avoid napping during the day: This client has not slept for 2 days, which exacerbates mania and disorientation. Preventing napping would worsen sleep deprivation. Instead, the nurse should promote rest whenever possible to help regulate mood, decrease agitation, and improve cognition in manic clients.

Rationale:

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.

B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.

C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.

D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.