A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?

 

A. This is not an appropriate action for a client experiencing acute mania. A flexible activity schedule may exacerbate symptoms by allowing too much freedom, leading to overstimulation and a lack of focus. Structured activities with clear boundaries are more effective for managing manic behaviors.

B. Providing high-calorie nutritional supplements is essential for clients in acute mania because they often exhibit hyperactivity and may neglect to eat or drink adequately. These supplements help maintain nutritional balance and prevent weight loss or dehydration during this period of heightened energy and poor self-care.

C. Allowing the client to eat meals alone in her room is not appropriate. Clients with acute mania benefit from supervised, structured environments to ensure they are eating and engaging in necessary self-care. Isolation may also increase feelings of disorganization or exacerbate symptoms.

D. Allowing the client to choose her clothes independently is not recommended during acute mania, as poor judgment and impulsivity may lead to inappropriate or excessive clothing choices. Providing simple, preselected clothing options helps reduce decision-making stress and ensures appropriate attire.

A. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.

C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.

D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.