A nurse is replacing the dressing for a client who is postoperative following thoracic surgery.
When assessing the surgical wound, which of the following findings should the nurse identify as an indication of infection?

Choice A rationale

Asking about the content of the voices helps the nurse assess for command hallucinations, which can pose a safety risk to the client or others. This open-ended question encourages the client to elaborate, providing crucial information about the severity, nature, and potential danger of the auditory stimuli, which is the primary goal of the assessment.

Choice B rationale

This question is counterproductive because it asks for a causal explanation that the client, due to their altered neurochemical state, cannot provide. It can also be perceived as challenging the reality of the client's experience, which invalidates their feelings and can damage the therapeutic relationship. This is not a therapeutic approach.

Choice C rationale

This redirects the conversation away from the client's immediate distress and the core issue of their hallucinations. While therapy is part of treatment, it may not be appropriate at this moment of crisis. The nurse’s priority is to first assess the immediate risk and support the client's immediate needs, before introducing another activity.

Choice D rationale

Asking about medication adherence can be perceived as accusatory and may cause the client to become defensive. While medication non-adherence can contribute to symptom exacerbation, the immediate priority is to assess the current risk level posed by the hallucinations, not to lecture the client about medication. This question is not therapeutic.

Choice A rationale

Scant lochia rubra with a few small clots is a normal finding at 2 days postpartum. Lochia rubra, which is dark red discharge, is expected during the first 3-4 days. Scant bleeding and small clots are considered normal and indicate the uterine healing process is progressing appropriately. Excessive bleeding or large clots would be cause for concern.

Choice B rationale

Bilateral ankle edema is a common and expected finding at 2 days postpartum. This is due to the mobilization of fluid retained during pregnancy and the effects of gravity. While it should be monitored, it typically resolves on its own. The nurse should assess for other signs of a more serious condition, such as unilateral leg swelling, pain, or redness, which could indicate a deep vein thrombosis.

Choice C rationale

A urine output of 2,500 mL/day is within the expected range for a postpartum client. Diuresis is a normal physiological process during the first few days after birth, as the body eliminates the excess fluid volume accumulated during pregnancy. Urine output typically ranges from 2,000 to 3,000 mL/day, indicating adequate kidney function and fluid mobilization.

Choice D rationale

Deep-tendon reflexes of 4+ are a hyperreflexic finding that can indicate a neurological complication, such as preeclampsia. Normal deep-tendon reflexes are typically 1+ to 2+. Hyperreflexia is a sign of central nervous system irritability and can precede seizure activity, making it a critical finding that requires immediate reporting to the provider for further assessment and intervention. .