A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic. Which of the following actions should the nurse perform first?

A. Gastric content pH: The pH of the gastric aspirate increased from 4.8 to 6.4, which may indicate a change in gastric emptying or possible contamination with intestinal contents. However, a pH of 6.4 alone is not an immediate reason to hold enteral feeding unless accompanied by other concerning signs.

B. Abdominal findings: The client has a distended, firm, and tense abdomen, which may indicate intolerance to the tube feeding, delayed gastric emptying, or possible bowel obstruction. These physical findings require immediate attention because continuing enteral feeding could worsen complications such as vomiting, aspiration, or bowel perforation.

C. Oxygen saturation: The client’s oxygen saturation is 96% on room air, which is within normal limits. While hypoxia can be a sign of aspiration or respiratory compromise, the current oxygenation does not indicate an immediate need to hold feeding or notify the provider.

D. Gastric residual: A residual volume of 90 mL with a pH of 6.4 suggests delayed gastric emptying or intolerance of the feeding. High residuals increase the risk of aspiration and indicate that the client may not tolerate additional enteral nutrition. Holding the feeding and notifying the provider is warranted to prevent complications.

E. Blood glucose: The client’s blood glucose is slightly elevated at 152 mg/dL, which falls within the range for administering correctional insulin per provider orders. Although ongoing monitoring is important, this glucose level does not require holding the feeding.

F. Laboratory electrolyte levels: The client’s potassium (3.7 mEq/L) and sodium (137 mEq/L) are within normal limits. There are no electrolyte abnormalities that would necessitate holding the tube feeding at this time, though continued monitoring is important for ongoing nutritional support.

A. Provide a flexible activity schedule: Clients experiencing acute mania often have high energy levels and may be unable to follow a flexible or self-directed schedule. Structured, brief, and supervised activities are more effective than a flexible schedule in managing behavior and ensuring safety.

B. Provide high-calorie nutritional supplements: Clients in acute mania may be too hyperactive or distracted to consume adequate meals. Offering high-calorie supplements helps prevent malnutrition and weight loss by providing concentrated nutrition in a format that is easier for the client to consume amidst hyperactivity.

C. Allow the client to eat meals alone in her room: Eating alone may increase the risk of inadequate intake because manic clients can be easily distracted or forget to eat. Supervised meals in a calm environment promote adequate nutrition and monitoring of intake.

D. Allow the client to choose her clothes independently: While promoting autonomy is generally important, clients in acute mania may select inappropriate or unsafe clothing due to impaired judgment. Providing guidance or limiting choices temporarily ensures safety and appropriateness of dress.