A nurse is providing teaching to a client who has gastritis. Which of the following instructions should the nurse include in the teaching?

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

A. Blood pressure: An elevated blood pressure of 148/94 mm Hg in a 30-week gestation client indicates potential preeclampsia. This requires follow-up, especially since it is accompanied by other preeclampsia symptoms such as headache and edema. Prompt assessment is essential to prevent progression to severe disease.
B. Respiratory assessment: The client’s respiratory rate is 20/min, even and non-labored, with clear breath sounds and 95% oxygen saturation. These are all within normal limits and do not indicate respiratory distress or compromise, so no immediate follow-up is necessary for this system.
C. Lower extremity assessment: 1+ dependent edema, though mild, can be an early sign of preeclampsia, especially when associated with elevated blood pressure and weight gain. This symptom requires monitoring for progression and possible systemic involvement.
D. Weight assessment: The client gained 0.68 kg (1.5 lb) in a week, which is above the normal range during the third trimester and may represent fluid retention. Coupled with hypertension and edema, it supports the suspicion of preeclampsia and warrants follow-up.
E. Fetal heart tracing: A fetal heart rate of 140/min is within the normal range of 110–160 bpm and shows no signs of distress. No immediate intervention is needed for fetal status at this time based on the tracing.
F. Nausea: Although nausea can be common in pregnancy, when it appears with headache and right upper quadrant pain, it may be part of the symptom complex for preeclampsia or HELLP syndrome. This combination should be followed up with further evaluation.
G. Fundal height: A fundal height of 29 cm at 30 weeks is within acceptable variation (±2 cm of gestational age), indicating appropriate fetal growth. This finding does not require follow-up at this time.
H. DTR: 3+ deep tendon reflexes suggest hyperreflexia, which is a neurological sign that can precede seizures in preeclampsia. When seen alongside elevated blood pressure and other systemic symptoms, it requires urgent follow-up to prevent maternal complications.