The nurse is caring for a client on a medical-surgical unit.

Which of the assessment findings require follow-up by the nurse? Select all that apply.

A. Monitor the dorsalis pedis pulse every 15 min: Frequent assessment of peripheral pulses, such as the dorsalis pedis, is essential after a cardiac catheterization to detect early signs of arterial occlusion, bleeding, or compromised circulation. Monitoring every 15 minutes during the initial post-procedure period allows timely identification of complications.

B. Place the client in Fowler's position: After a femoral cardiac catheterization, the client is typically positioned supine with the affected leg straight to minimize bleeding and hematoma formation. Fowler’s position can increase stress on the groin puncture site and is not recommended immediately post-procedure.

C. Keep the client NPO for 24 hr: NPO status is not routinely required for 24 hours following cardiac catheterization. Clients may resume oral intake as tolerated once hemodynamically stable, unless contraindicated for other medical reasons.

D. Maintain strict bedrest for the first 12 hr: While bedrest is necessary immediately post-procedure, strict immobility is usually required for 2–6 hours, depending on the type of closure device or sheath used. Maintaining 12 hours of strict bedrest is longer than standard protocol and may unnecessarily increase discomfort and risk of complications like urinary retention.

Rationale:

• Pressured speech: The client demonstrates rapid, loud, and nonstop speech, characteristic of mania. Pressured speech reflects heightened energy, distractibility, and decreased need for rest, all typical of a manic episode. It is not a primary symptom of psychosis, although severe psychotic agitation can sometimes alter speech.

• Hallucinations: The client reports seeing a person who is not present and interacting with them, which is a hallmark of psychosis. These perceptual disturbances indicate impaired reality testing. Hallucinations are less common in purely manic states unless mania is accompanied by psychotic features. Here, the client’s persistent visual hallucinations support a diagnosis of psychosis.

• Disorganized thought process: The client exhibits disorganized and tangential speech, reflecting difficulty organizing thoughts. Disorganization is characteristic of psychotic disorders due to impaired reality testing and cognitive processing. It can also appear in mania, particularly when the client exhibits distractibility, racing thoughts, and pressured speech.

• Lack of sleep: The client has gone at least 2 days without sleeping, a classic sign of mania. Decreased need for sleep with preserved energy is typical in manic episodes. Sleep deprivation alone does not indicate psychosis unless accompanied by hallucinations or delusions.

• Excessive spending habits: The client exhibits impulsive financial behavior, giving away large sums of money and overspending. This risk-taking and poor judgment are hallmark features of mania. Such behaviors are less commonly associated with psychosis unless delusions drive them.