A patient has been hospitalized after her house was destroyed in a hurricane.
She has spent two weeks in the intensive care unit and has now been transferred to the surgical floor for continued respiratory monitoring and completion of IV antibiotic therapy.
The patient reports a pain level of 2 on a scale of 0 to 10. She requests sleeping medication, explaining that she is haunted by distressing thoughts and memories of the house collapsing, which prevent her from sleeping.
She says, “I used to be so happy before all of this happened.
Now I can’t seem to get out of this funk I am in.”. She would also prefer a quieter area of the unit as she is currently near the nurses’ station and is disturbed by the noise.
After listening to the patient’s symptoms, the nurse suspects that she likely has:

Choice A rationale

A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.

Choice B rationale

A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.

Choice C rationale

Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.

Choice D rationale

A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.

Choice A rationale

Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.

Choice B rationale

Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.

Choice C rationale

Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.

Choice D rationale

Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.