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A nurse is caring for a client who has been admitted to the hospital.

Exhibits

Select the 5 actions the nurse should take.

Restrict the client's sodium intake.

Provide frequent rest periods for the client.

Assess the client's level of orientation.

Instruct the client to avoid blowing their nose forcefully.

Place the client on a low-carbohydrate diet.

Place the client under contact isolation.

Advise the client to avoid the use of soap and alcohol-based lotions.

Answer and Explanation

Correct Answer : A,B,C,G

A.   Restrict the client's sodium intake
One of the common complications of cirrhosis and liver disease is ascites (fluid accumulation in the abdomen), and hyponatremia (low sodium) may develop due to the body's altered fluid balance. Sodium restriction is a key part of managing ascites and preventing further fluid buildup.
B.   Provide frequent rest periods for the client
Fatigue and weakness are common symptoms of liver disease and cirrhosis. The client is likely experiencing decreased energy levels due to liver dysfunction, so it is important to provide frequent rest periods to help prevent further fatigue and promote overall well-being.
C.   Assess the client's level of orientation
Disorientation to time and changes in mental status are common in clients with liver disease, particularly due to the development of hepatic encephalopathy, a condition where toxins (like ammonia) accumulate in the blood and affect brain function.
D.   Instruct the client to avoid blowing their nose forcefully
This action is typically suggested for clients at risk for bleeding (e.g., those with low platelet counts or clotting disorders). Although the client does have thrombocytopenia (low platelet count), there is no evidence in the provided data that the client is at immediate risk for epistaxis (nosebleeds).
E.   Place the client on a low-carbohydrate diet
Clients with liver disease typically benefit from a high-calorie, high-protein diet to support healing and provide energy. A low-carbohydrate diet is not indicated unless there are other factors like diabetes or fatty liver disease, which is not suggested by the information provided.
F.   Place the client under contact isolation
Contact isolation is generally used to prevent the spread of infectious diseases that are transmitted through direct contact with the patient or their environment (e.g., MRSA, C. difficile). There is no
indication that this client has a contagious infection that would require isolation. The client’s symptoms are more indicative of liver disease and complications of cirrhosis, rather than an infectious condition that would require isolation.
G.   Advise the client to avoid the use of soap and alcohol-based lotions
Clients with liver disease often experience dry skin and pruritus (itching), which can be aggravated by harsh soaps and alcohol-based lotions. The yellowing of the sclera (jaundice) and itching (pruritus) are symptoms commonly seen in liver dysfunction, and using gentle skin care products without harsh chemicals will help minimize irritation and soothe the skin.

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Correct Answer is []

Explanation

Potential Condition:

The client is most likely experiencing Brief Psychotic Disorder.

Behavioral Clues: The client’s behavior, including running from EMS, shouting “No, you are not going to kill me,” and appearing disheveled with odd behaviors like mumbling and talking to themselves, is suggestive of a psychotic episode.
Acquaintance Report: The acquaintance reports that the client has exhibited odd behaviors (e.g., talking when no one is present and being suspicious of everyone). This could be indicative of a pattern of behavior seen in brief psychotic disorder.
Client History: The client mentions episodes of similar behavior starting at age 19, which is consistent with the onset of brief psychotic disorder in early adulthood.

Actions to Take:

Engage with the client several times each day to establish trust:

In a psychotic state, it is important to create a trusting relationship. Building rapport helps the nurse understand the client’s perceptions and reality, while also reducing anxiety and providing reassurance. Engagement should be frequent and supportive to avoid alienating the client and to create a safe, comforting environment.

Reduce external stimuli:

In brief psychotic disorder, external stimuli can overwhelm the client’s perception and exacerbate hallucinations or delusions. Reducing noise, unnecessary people, or overwhelming stimuli can help reduce agitation and improve the client’s ability to focus and function.

Parameters to Monitor:

Suicide Risk:

Clients with psychotic disorders, particularly those experiencing delusions and hallucinations, are at an increased risk of self-harm or suicidal ideation. The nurse must assess the client's thoughts and feelings related to harm to themselves, especially given the potential disconnection from reality.

Temperature:

Although the client's temperature is normal (37°C), psychotic episodes, particularly those that are intense or prolonged, can cause the body to become dysregulated. It's important to monitor the temperature as fever can indicate physical distress or complications (e.g., medication side effects).

Rationale for other conditions;

Substance Use Disorder: There is no evidence of current intoxication or withdrawal in the lab results (blood alcohol is 0 mg/dL), so substance use disorder is unlikely.

Delirium: The lab results and vital signs are within normal limits, and the client’s history does not suggest a medical issue that could cause delirium, such as infections or metabolic disturbances.

Anxiety: While anxiety could contribute to the client feeling “hot” or distressed, the client's psychotic behaviors (e.g., delusions, hallucinations) go beyond typical anxiety and suggest a more serious psychotic disorder.

A. Fibromyalgia B. Fibrocystic breast disease C. Renal calculi D. Hypertension.

Correct Answer is D

Explanation

A. Fibromyalgia is not a contraindication for combination oral contraceptives.
B. Fibrocystic breast disease is not a contraindication, though it may require monitoring.
C. Renal calculi are not a contraindication for oral contraceptive use.
D. Hypertension is a contraindication because it increases the risk of cardiovascular complications when using combination oral contraceptives.

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A nurse is caring for a client who has been admitted to the hospital. Exhibits Select the 5 actions the nurse should take.

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A nurse is caring for a client who has been admitted to the hospital.

Exhibits

Select the 5 actions the nurse should take.