Nurses' Notes Postoperative Day 3 0900:

The client reports pain at the surgical incision site as 5 on a scale of 0 to 10. The client reports bladder fullness. Perineal dressing intact with minimal serosanguinous drainage. The client transferred out of bed to a chair independently. Extremities cool and dry with 2+ peripheral pulses.

1300:

The client reports abdominal cramping and small, hard, painful bowel movements after lunch. Ambulating independently in the hallway. Reports pain as 8 on a scale of 0 to 10. Urinary catheter intact with 100 mL/hr. of pink urine.

Select the 2 actions the nurse should prepare to take for the client.

A. Incorrect. Decreased platelets are not typically associated with infection but can be indicative of bleeding disorders.
B. Incorrect. Increased iron levels are not directly related to infection but can be associated with conditions like hemochromatosis.
C. Correct. An increased erythrocyte sedimentation rate (ESR. is it a common indicator of inflammation and infection? It reflects the rate at which red blood cells settle in a tube over a specific period.
D. Incorrect. Decreased hemoglobin levels are not specific to infection but can be seen in various conditions, including anemia.

The correct answer is Choices B and D.

Choice A rationale: Using confrontation to manage a client’s behavior is not recommended, especially for clients with Alzheimer’s disease. Confrontation can lead to increased agitation, confusion, and distress in these clients. It’s important to approach clients with Alzheimer’s disease in a calm, reassuring manner and to validate their feelings and experiences.

Choice B rationale: Limiting the number of choices for the client is a beneficial strategy when caring for clients with Alzheimer’s disease. Too many choices can overwhelm these clients and lead to increased confusion and frustration. By simplifying decisions, caregivers can help to reduce the client’s stress and improve their ability to function.

Choice C rationale: While it’s important to keep clients with Alzheimer’s disease engaged and stimulated, providing a stimulating environment can be counterproductive. Too much stimulation can overwhelm these clients and lead to increased confusion and agitation. It’s more beneficial to provide a calm, quiet, and familiar environment for these clients.

Choice D rationale: Using written signs to assist the client with locating the bathroom can be very helpful for clients with Alzheimer’s disease. As the disease progresses, these clients often struggle with memory loss and disorientation. Clear, simple signs can help them navigate their environment and maintain a level of independence.