A nurse on an inpatient mental health unit is caring for a client.

Exhibits

Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis

Rationale:

A. "You can lift objects that weigh 15 pounds.": Clients recovering from retinal detachment repair should avoid lifting heavy objects, even as light as 15 pounds. Increased intraocular pressure from straining can compromise the surgical repair.

B. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure and should be avoided postoperatively. Clients are advised to bend at the knees and keep their head upright to reduce pressure on the eye.

C. "Avoid reading for 3 days following surgery.": Reading is usually restricted only if it causes eye strain or requires eye movement that could interfere with healing. It is not routinely restricted for a set number of days unless otherwise specified by the surgeon.

D. "Take a stool softener daily.": Straining during bowel movements increases intra-abdominal and intraocular pressure. Stool softeners help prevent straining, making them a useful part of postoperative care after eye surgery to protect the surgical site.

Rationale for Correct Choices:

• Pain medication: Pain control is a primary concern in fracture management, especially in pediatric clients. This child reports a pain score of 4/10, indicating discomfort. Administering pain medication will reduce suffering and help prevent complications such as anxiety or guarding, which may impair healing.
• Limb immobilization: Immobilization stabilizes the fracture site and prevents further injury to soft tissues or neurovascular structures. With a nondisplaced fracture of both radius and ulna, the nurse should expect a splint or cast order to limit movement and aid in bone alignment and healing.

Rationale for Incorrect Choices:

• Bed rest: Bed rest is not required for isolated upper limb fractures, particularly when the child is developmentally appropriate, alert, and ambulatory. Encouraging mobility is important to reduce the risk of complications like deconditioning or thromboembolism.
• Surgical consultation: A nondisplaced fracture typically does not require surgical intervention unless complications develop. Surgical consultation is more often necessary for open, displaced, or unstable fractures that require reduction or fixation.
• Antibiotics: There are no signs of systemic or localized infection. The child has a superficial knee abrasion but no open fracture or wound that would necessitate prophylactic antibiotics. Therefore, antibiotic use is not indicated in this situation.