A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?

Maintain trust and avoid behaviors that may increase agitation.

Order the client to go to their room & alert security.

Tell the client to sit down or risk isolation and loss of privileges.

Sedate the client after collecting a lithium level.

Answer and Explanation

The Correct Answer is A

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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Correct Answer is C

Explanation

Chicken breast, green beans, and a glass of milk. This is because chicken breast is a good source of protein, which is essential for wound healing. Green beans are rich in vitamin C, which helps with collagen synthesis and immune function. Milk is a good source of calcium and vitamin D, which are important for bone health and healing.

Choice A is wrong because cheese pizza and french fries are high in fat and sodium, which can increase inflammation and delay wound healing. Orange juice is high in sugar, which can also impair wound healing and increase the risk of infection.

Choice B is wrong because cheeseburger and potato chips are also high in fat and sodium, and have similar effects as choice A. Soda is also high in sugar and can cause dehydration, which can slow down wound healing.

Choice D is wrong because spaghetti and meatballs are high in refined carbohydrates, which can spike blood sugar levels and impair wound healing.

A roll is also a refined carbohydrate and does not provide much fiber or nutrients. Chocolate pudding is high in sugar and fat, and can also worsen wound healing.

A. Hemoglobin = 14.2 g/dL. B. Potassium = 4.2 mEq/L. C. Albumin = 2.8 g/dL. D. Creatinine = 0.8 mg/dL.

Correct Answer is C

Explanation

Albumin is a protein that is made by the liver and helps maintain fluid balance in the

body. The normal range for albumin is 3.5 to 5.5 g/dL or 35-55 g/liter. A low albumin level can indicate malnutrition, liver disease, kidney disease, inflammation, or other conditions that affect protein synthesis or loss.

A client diagnosed with Imbalanced Nutrition: Less than Body Requirements would be expected to have a low albumin level due to inadequate protein intake or absorption.

Choice A is wrong because hemoglobin = 14.2 g/dL is within the normal range for males, which is 13.2 to 16.6 g/dL.

Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. A low hemoglobin level can indicate anemia, which can be caused by blood loss, iron deficiency, vitamin B12 deficiency, or other conditions that affect red blood cell production or destruction.

Choice B is wrong because potassium = 4.2 mEq/L is within the normal range for adults, which is 3.5 to 5 mEq/L.

Potassium is an electrolyte that helps regulate fluid balance, nerve impulses, and muscle contractions. A low potassium level can indicate dehydration, diarrhea, vomiting, diuretic use, or other conditions that cause potassium loss. A high potassium level can indicate kidney disease, adrenal insufficiency, acidosis, or other conditions that cause potassium retention.

Choice D is wrong because creatinine = 0.8 mg/dL is within the normal range for adults, which is 0.6 to 1.2 mg/dL.

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?