A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Rationale for Correct Choices:

• Decrease environmental stimulation: Reducing stimulation helps manage restlessness by preventing sensory overload, which can exacerbate agitation in clients with schizophrenia. A calm environment supports focus and reduces the risk of escalation or aggressive behavior.
• Provide constructive diversions: Constructive diversions such as quiet activities or art can channel aggressive energy into safe outlets. For a client expressing paranoia and aggression toward staff, structured and non-threatening engagement is therapeutic and promotes emotional regulation.
• Use visual cues to promote attention to tasks: Clients with schizophrenia often struggle with distractibility and disorganized thought processes. Visual prompts and step-by-step guides help them focus and complete hygiene tasks that would otherwise be overwhelming or forgotten.

Rationale for Incorrect Choices:

• Avoid discussing the client’s negative emotions: Suppressing emotional expression is countertherapeutic. Clients benefit from validating their emotions through supportive communication, which also builds trust and rapport necessary for effective care.
• Discourage participation in physical exercise: Exercise can be beneficial in reducing anxiety and agitation. Discouraging movement may increase restlessness or internal distress in clients who need outlets for excess energy.
• Minimize engagement with the client: Withdrawal from the client may reinforce feelings of paranoia or abandonment. Consistent therapeutic engagement is essential for building trust and managing disruptive behaviors.
• Place the client in a room away from the nurses’ station: Isolating a paranoid and aggressive client may increase their risk of harming themselves or others. Close observation near the nurses’ station ensures safety and quick intervention if escalation occurs.
• Instruct client to perform tasks independently: Clients with cognitive disruptions may not be able to initiate or complete hygiene without cues. Expecting full independence without support can lead to frustration, noncompliance, or neglect of self-care.
• Enact consequences for uncompleted hygiene tasks: Punitive measures are inappropriate for clients with psychiatric disorders who are impaired in their ability to carry out daily routines. Behavioral reinforcement must be therapeutic and supportive, not disciplinary.

Rationale:

• Parotid glands: Parotid gland enlargement is a typical finding in clients with bulimia nervosa due to repeated episodes of self-induced vomiting. The recurrent stimulation of salivary glands leads to painless swelling, often bilateral, and may also contribute to facial puffiness or a rounded appearance.
• Potassium level: A potassium level of 3.0 mEq/L is low and may result from either bulimia nervosa or anorexia nervosa. In bulimia, this is typically due to purging through vomiting or laxative use; in anorexia, it stems from prolonged restriction, dehydration, and possible diuretic misuse. Both conditions increase the risk of cardiac complications.
• Weight: The client’s weight of 61.8 kg with a BMI of 20.7 falls within the normal range and is more consistent with bulimia nervosa. Individuals with anorexia nervosa usually present with a significantly lower body weight and BMI, typically below 18.5, due to extreme caloric restriction and prolonged starvation.
• Sodium level: A sodium level of 134 mEq/L is slightly low and can occur in both bulimia nervosa and anorexia nervosa. In bulimia, frequent vomiting may cause sodium loss, while in anorexia, hyponatremia can develop from malnutrition, dehydration, or excessive water intake in attempts to suppress appetite or manipulate weight.
• Hand findings: Calluses on the index and middle fingers, known as Russell’s sign, are associated with bulimia nervosa. These result from repeated trauma during induced vomiting episodes, as the hand comes into contact with the teeth. This finding is a classic physical sign of chronic purging behavior.