A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Rationale:

A. "I will wait 1 hour after getting up in the morning to have breakfast.": Delaying breakfast may worsen nausea, as symptoms of hyperemesis gravidarum are often worse in the morning. It is recommended to eat a small, dry carbohydrate-rich snack, such as crackers, soon after waking.

B. "I will try to eat balanced meals instead of only foods that appeal to my taste.": While balanced meals are ideal, during hyperemesis gravidarum, the priority is tolerating any nutrition. Clients are encouraged to eat whatever foods they can tolerate, as nutritional intake is often severely limited.

C. “I will eat or drink something every 2 to 3 hours throughout the day": Eating or drinking small amounts frequently helps prevent an empty stomach, which can trigger or worsen nausea and vomiting. This approach improves tolerance and supports hydration and nutrition.

D. “I will eat a low protein snack 30 minutes before going to bed each night.": Protein-rich snacks, not low-protein ones, are better for stabilizing blood glucose levels overnight and may help reduce morning nausea. A high-protein snack before bed is more appropriate.

Rationale:

• Pneumonia: The child’s shallow respirations, diminished breath sounds at the bases, and ongoing refusal to use the incentive spirometer suggest decreased lung expansion and poor airway clearance. These are classic risk factors for postoperative pneumonia, especially in pediatric clients who are reluctant to engage in deep breathing exercises.
• Peritonitis: Peritonitis would be indicated by signs such as a rigid abdomen, rebound tenderness, or marked fever. The client has mild abdominal tenderness but not the severity or systemic signs expected with peritonitis.
• Wound infection: There are no signs of wound infection. The surgical dressing is consistently described as dry and intact with no redness, drainage, or swelling, which are typical indicators of infection.
• Temperature: The child's temperature is slightly elevated but remains within the low-grade range and does not independently indicate a serious complication. It’s not the most significant factor in this case.
• Bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery and do not directly point to a respiratory complication. They are improving postoperatively and are not a primary concern for pneumonia.
• Breathing effort: The child’s consistently shallow respirations and diminished breath sounds show a risk for poor ventilation. These are warning signs for the development of postoperative pneumonia.
• Abdominal tenderness: Mild to moderate tenderness is expected 1 day after abdominal surgery and shows improvement over time. It is not strongly suggestive of a new or worsening condition like pneumonia.
• Refusal to use incentive spirometer: Using the incentive spirometer encourages deep breathing and lung expansion. Refusing it increases the risk of atelectasis and subsequent pneumonia, especially in pediatric clients with shallow breathing patterns.
• Surgical dressing: The dressing is consistently described as dry and intact with no signs of infection or complication. It does not point to any current or developing risk.