A patient is being treated on the mental health unit for an anxiety disorder. The patient approaches the nurse and reports feeling dizzy and weak, with a sensation of a racing heart. The nursing care plan includes interventions of imagery exercises and as-needed lorazepam (Ativan) for symptoms of anxiety. What should the nurse do first?

Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.

Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.

Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.

Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.

Choice A reason: Coughing and deep breathing exercises after surgery are encouraged to prevent atelectasis, which is the collapse of part or (less commonly) all of a lung.

Choice B reason: Induction is not a postoperative complication; it refers to the process of initiating anesthesia.

Choice C reason: Hypothermia is a condition of abnormally low body temperature, not directly prevented by coughing and deep breathing.

Choice D reason: Hematoma, a collection of blood outside of blood vessels, is not prevented by coughing and deep breathing exercises.