A nurse is caring for a client in a clinic.

Exhibits

For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

Note: Each drop down must have 1 response selected.

A. Keep a monthly calendar in the client's kitchen: A calendar showing a full month may be difficult for a client with Alzheimer's disease to process due to impaired memory and orientation. Simpler visual aids or daily reminders are more effective in supporting cognitive function.
B. Provide distraction by keeping the television on: Leaving the television on continuously can overstimulate the client and contribute to confusion or agitation. Clients with Alzheimer's often benefit more from calm, structured environments than from constant auditory input.
C. Install a nightlight in the client's bedroom: Installing a nightlight helps maintain orientation and reduce nighttime confusion. It also lowers the risk of falls by making it easier for the client to navigate their environment if they wake during the night.
D. Place a deadbolt lock on the client's bedroom door: Locking the client in their bedroom poses serious safety concerns, especially in emergencies like a fire. It may also increase anxiety or fear. Safer wandering prevention measures include door alarms or monitoring systems.

Rationale for Correct Findings:

• WBC count 33,000/mm³: A significantly elevated white blood cell count strongly suggests a serious postpartum infection such as endometritis or sepsis, especially in a client with additional risk factors like cesarean birth and prolonged rupture of membranes.
• Moderate amount of dark brown, foul-smelling lochia: Malodorous lochia is a hallmark sign of uterine infection. This finding, in conjunction with uterine tenderness and systemic symptoms, indicates likely endometritis.
• Client reports feeling unwell: A nonspecific but important early sign of infection or systemic compromise. This symptom, when paired with objective findings, warrants prompt clinical attention.
• Fundus boggy but firmed with massage, uterus tender to palpation: A boggy uterus suggests uterine atony, which increases hemorrhage risk. Although it responds to massage, it reflects poor uterine tone and requires monitoring. Tenderness supports the likelihood of endometritis,
• Temperature 38.2° C (100.8° F): A postpartum temperature above 38° C, particularly after 24 hours, is considered abnormal and may indicate infection, especially when supported by other abnormal findings.

Rationale for Incorrect Findings:

• Respiratory rate 18/min is within acceptable limits and do not indicate an immediate respiratory or circulatory emergency.

• Surgical incision well approximated with slight edema; no redness or drainage: Minor swelling without other signs of infection (e.g., erythema, warmth, discharge) is expected and does not require urgent intervention.
• No bowel movement since birth, hypoactive bowel sounds: Bowel inactivity is common postpartum, especially after cesarean and general anesthesia. While this warrants monitoring, it is not a priority unless symptoms worsen.
• Lung sounds clear but diminished in the bases. This is commonly observed postpartum, especially following cesarean delivery under general anesthesia. It may be due to decreased mobility, shallow breathing, or atelectasis. While it is a point to monitor it is not urgent