A nurse is talking to a client who has schizophrenia and reports experiencing auditory hallucinations. Which of the following responses should the nurse make?

Rationale for correct choices

• Stroke: The client developed new-onset atrial fibrillation with a rapid ventricular response, which significantly increases the risk for thrombus formation and subsequent embolic stroke. Atrial fibrillation after cardiac surgery can lead to stasis of blood in the atria, particularly the left atrial appendage, predisposing the client to cerebrovascular events.

• Cardiac rhythm: Monitoring cardiac rhythm is essential because changes such as atrial fibrillation, tachyarrhythmias, or pauses indicate altered hemodynamics and potential complications. The irregular, rapid atrial fibrillation observed at 1130 highlights the client’s immediate risk for embolic events. Continuous cardiac monitoring allows prompt recognition and intervention to prevent stroke

Rationale for incorrect choices

• Atelectasis: Atelectasis would present with diminished lung sounds, crackles, dyspnea, or hypoxemia. In this case, lung sounds are clear bilaterally, oxygen saturation is slightly decreased but not critically low, and the client reports no respiratory distress. These findings make atelectasis less likely.

• Cardiac tamponade: Cardiac tamponade is characterized by hypotension, jugular venous distension, muffled heart sounds, and tachycardia. Although the client has tachycardia, blood pressure is only mildly decreased, JVD is absent, and heart sounds are normal. These findings do not support cardiac tamponade at this time.

• Pneumothorax: Pneumothorax would present with diminished or absent lung sounds on the affected side, sudden dyspnea, and decreased oxygen saturation. Lung sounds are clear bilaterally, chest tubes are patent, and oxygen saturation is only slightly decreased, which is insufficient evidence for pneumothorax.

• Infection: Early postoperative infection might present with fever, redness, or drainage at surgical sites. The client’s dressings are clean, dry, and intact, with only a mild temperature elevation, which may be a normal postoperative response rather than a true infection. There is no other clinical evidence to support infection as an immediate concern.

• Chest tube assessment: Chest tube assessment is important for monitoring pneumothorax or fluid accumulation but is not related to the immediate risk of stroke. The chest tubes are patent, with tidaling present and no air leak, indicating proper function. This parameter does not reflect the client’s thromboembolic risk.

• Lung sounds: Lung sounds are clear and do not indicate respiratory compromise or atelectasis. While important for overall assessment, lung auscultation does not provide evidence of the client’s risk for stroke in the context of new atrial fibrillation.

• Heart sounds: Heart sounds are normal with no extra sounds or murmurs. While auscultation is part of cardiac assessment, the primary risk for stroke is related to the cardiac rhythm rather than auscultatory findings.

• Dressing assessment: Dressings are clean, dry, and intact, indicating no current surgical site complications. This parameter does not contribute to identifying the client’s stroke risk.

A. Assist the client to a supine position: There is no requirement to maintain a supine position for bacterial meningitis. Clients are often more comfortable with the head of the bed elevated to reduce intracranial pressure and promote comfort. Supine positioning alone does not prevent disease transmission or improve outcomes.

B. Recommend prophylactic acyclovir for the client's family: Acyclovir is an antiviral medication and is not effective against bacterial infections. Family members may require prophylactic antibiotics if exposed, but antiviral therapy is inappropriate for bacterial meningitis.

C. Initiate droplet precautions for the client: Bacterial meningitis, particularly Neisseria meningitidis, can be transmitted via respiratory droplets. Implementing droplet precautions, including the use of masks and limiting close contact, protects healthcare staff and other clients from infection. This is a standard and critical infection control measure.

D. Perform a Glasgow Coma Scale every 24 hr: Clients with bacterial meningitis are at risk for rapid neurological changes. Performing a Glasgow Coma Scale only once every 24 hours is insufficient. Neurological status should be monitored more frequently to promptly identify deterioration.