A nurse is assessing a client who is using crutches as an assistive device due to a right hip fracture. Which of the following actions should the nurse take prior to planning the client's care?

Rationale:

• Encourage the client to avoid napping during the day: A manic client has a severely diminished drive for sleep and is at risk for physical exhaustion. Any opportunity for rest or sleep, even a brief nap, should be encouraged to protect the client's physiological health.

• Minimize environmental stimuli for the client: Manic clients are highly distractible and easily overstimulated. Reducing noise, dimming lights, and providing a private room helps decrease the "manic energy" and promotes safety and calm.

• Provide the client with high-calorie fluids every hr: The client has not eaten for an extended period and exhibits poor recall of the last meal, indicating risk of malnutrition. High-calorie fluids are an appropriate intervention to ensure adequate caloric intake and hydration, thus supporting metabolic needs during the maniac episodes.

• Weigh the client each day: Daily weight monitoring helps track nutritional status and detect early signs of fluid imbalance or rapid weight loss, which can occur in clients with poor intake or hyperactivity during mania. It also assists in evaluating effectiveness of nutritional interventions. This practice provides objective data to guide care planning and assess health risks associated with inadequate intake.

A. Updating a family member on a client's condition following surgery: Communicating clinical information and updates to family members requires professional nursing judgment and understanding of the client’s status. This task cannot be delegated to assistive personnel because it involves interpretation of medical information and legal responsibility.

B. Observing a client's abdominal laceration for indications of infection: Assessment of wounds for signs of infection requires professional knowledge and clinical judgment to identify subtle changes and make appropriate care decisions. This task must be performed by a licensed nurse and cannot be delegated to assistive personnel.

C. Instructing a client about the use of an incentive spirometer: Teaching a client involves providing information, evaluating understanding, and demonstrating correct technique. This requires nursing knowledge and judgment, making it inappropriate to delegate to assistive personnel.

D. Documenting the amount of drainage from a client's NG tube: Measuring and recording output from an NG tube is a routine, non-invasive task that does not require clinical judgment. This task can be safely delegated to assistive personnel as long as they follow proper procedures and report abnormal findings to the nurse.