A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.

Offer the client fluids high in fiber and protein every hour. This is because clients who have bipolar disorder and are experiencing mania are at risk of dehydration, malnutrition, and weight loss due to increased activity, poor intake, and impaired judgment. Fluids high in fiber and protein can help prevent constipation and promote satiety.

Choice B is wrong because monitoring the client’s vital signs twice per day is not enough for a client who has mania. The nurse should monitor the client’s vital signs more frequently, at least every 4 hours, to assess for signs of dehydration, infection, or cardiac complications.

Choice C is wrong because encouraging the client to participate in group therapy activities each day can increase the client’s stimulation and agitation. The nurse should provide a calming environment with fewer stimuli and solitary activities for a client who has mania.

Choice D is wrong because weighing the client three times per week is not sufficient for a client who has mania. The nurse should weigh the client daily to monitor for weight loss and fluid imbalance.

This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.

Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.

Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.

Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.