A nurse is preparing to administer a nasogastric (NG) tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

Rationale:

• Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
• Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
• Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
• Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
• Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.

A. A client who is taking warfarin and has started to breastfeed: Warfarin passes into breast milk in very small amounts and is generally considered compatible with breastfeeding. However, the infant’s coagulation status should be monitored, and follow-up with the healthcare provider is appropriate to ensure safety.

B. A client who is taking bumetanide and reports an increase in urinary frequency: Increased urination is an expected pharmacologic effect of loop diuretics like bumetanide. This finding does not require follow-up unless accompanied by other concerning symptoms.

C. A client who received a Mantoux test 48 hr ago and has an induration: A positive Mantoux test requires interpretation by a healthcare provider, but the presence of induration alone is a normal finding that triggers standard follow-up for tuberculosis screening.

D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: Sodium phosphate is commonly used as a bowel prep for colonoscopy. As long as the client follows the prescribed instructions and has no contraindications, this does not require additional follow-up.