A nurse is caring for a client in the emergency department (ED).
Which of the following interventions should the nurse implement?
Stay with the client.
Place the client in a room close to the nurses' station.
Offer the client a caffeinated beverage.
Weigh the client daily.
Offer the client finger foods.
Correct Answer : A
It is essential for the nurse to stay with the client in this situation. The client's presentation indicates manic behavior, which can be associated with bipolar disorder. Manic episodes can lead to increased energy levels, decreased need for sleep, agitation, and impulsivity. The client's refusal to sit down, pacing, and becoming agitated when asked questions all indicate potential risk to themselves or others. Staying with the client ensures their safety and the safety of others in the environment. The nurse can provide verbal support, prevent potential harm, and de-escalate the situation if needed.
Placing the client in a room close to the nurses' station might be helpful for monitoring and quick assistance, but it doesn't directly address the client's immediate agitation and need for supervision. The priority in this scenario is to ensure the client's safety, which can be achieved by staying with them.
Offering the client a caffeinated beverage is not appropriate in this situation. Caffeine can exacerbate agitation and restlessness, potentially worsening the client's symptoms. It's important to provide a calm and supportive environment instead.
Weighing the client daily is not relevant to the current situation. The client's agitation and need for supervision take precedence over routine assessments like daily weight measurement.
Offering the client finger foods is also not appropriate in this situation. The client's behavior and presentation suggest a manic episode, and their agitation indicates that they are not in a state to engage in eating. Ensuring safety and providing emotional support are the immediate priorities.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure.
Choice B rationale:
Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs.
Choice C rationale:
This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury.
Choice D rationale:
A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.
Correct Answer is B
Explanation
Choice A rationale:
Iron 100 mcg/dL The normal range for serum iron levels can vary based on age and gender, but typically, a range of 50 to 150 mcg/dL is considered normal. The provided value of 100 mcg/dL falls within this range and is not a cause for concern. Elevated iron levels can be indicative of hemochromatosis or other disorders, but this value is not concerning.
Choice B rationale:
Hemoglobin 8 g/dL Hemoglobin levels can vary by age and gender, but in general, a hemoglobin level of 8 g/dL is low and suggestive of anemia, a condition characterized by a reduced ability of the blood to carry oxygen. Anemia can lead to fatigue, weakness, and other symptoms, and the nurse should report this finding to the healthcare provider for further evaluation and management.
Choice C rationale:
Sodium 140 mEq/L The normal range for serum sodium levels is typically around 135 to 145 mEq/L. The provided value of 140 mEq/L falls within this normal range and is not a cause for concern. Deviations from this range can indicate various conditions, including dehydration or overhydration, but this value is within an acceptable range.
Choice D rationale:
Calcium 9 mg/dL The normal range for serum calcium levels can vary, but generally, a range of 8.5 to 10.5 mg/dL is considered normal. The provided value of 9 mg/dL falls within this range and is not significantly abnormal. Abnormal calcium levels can be indicative of various conditions, including thyroid disorders or kidney problems, but this value is not concerning.
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