A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.

Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.

Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.

Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.

Choice A reason: This is an important action, but not the first one. The nurse should obtain sample menus from the dietitian to give to the client after assessing the client's food preferences, needs, and goals. The sample menus should be individualized and tailored to the client's lifestyle, culture, and preferences.

Choice B reason: This is the first action, because the nurse should ask the client to identify the types of foods she prefers before providing any dietary teaching. This can help the nurse to determine the client's current eating habits, knowledge, and readiness to learn. It can also help the nurse to establish rapport and trust with the client, and to involve the client in the decision-making process.

Choice C reason: This is an important action, but not the first one. The nurse should identify the recommended range for the client's blood glucose level after assessing the client's food preferences, needs, and goals. The recommended range for the blood glucose level depends on the type, dose, and timing of the medication, the frequency and intensity of the exercise, and the carbohydrate intake of the client.

Choice D reason: This is an important action, but not the first one. The nurse should discuss long-term complications that can result from nonadherence to the dietary plan after assessing the client's food preferences, needs, and goals. The long-term complications of diabetes mellitus include cardiovascular disease, kidney disease, nerve damage, eye damage, and foot problems. The nurse should explain the benefits of following the dietary plan and the risks of not following it.