A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field, which of the following is an expected finding?

A. This is not an appropriate action for a client experiencing acute mania. A flexible activity schedule may exacerbate symptoms by allowing too much freedom, leading to overstimulation and a lack of focus. Structured activities with clear boundaries are more effective for managing manic behaviors.

B. Providing high-calorie nutritional supplements is essential for clients in acute mania because they often exhibit hyperactivity and may neglect to eat or drink adequately. These supplements help maintain nutritional balance and prevent weight loss or dehydration during this period of heightened energy and poor self-care.

C. Allowing the client to eat meals alone in her room is not appropriate. Clients with acute mania benefit from supervised, structured environments to ensure they are eating and engaging in necessary self-care. Isolation may also increase feelings of disorganization or exacerbate symptoms.

D. Allowing the client to choose her clothes independently is not recommended during acute mania, as poor judgment and impulsivity may lead to inappropriate or excessive clothing choices. Providing simple, preselected clothing options helps reduce decision-making stress and ensures appropriate attire.

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.