A nurse is caring for a client.

For each assessment finding, click to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

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. Perform bimanual fundal massage: Excessive vaginal bleeding postpartum often indicates uterine atony. Performing a bimanual fundal massage helps stimulate uterine contraction, which can reduce hemorrhage. This is a primary and immediate intervention in postpartum bleeding management.

B. Weigh perineal pads: Weighing pads helps quantify blood loss but does not actively stop hemorrhage. While important for assessment and documentation, it is not the first action when the client is actively bleeding.

C. Initiate oxygen at 2 L/min via nasal cannula: Administering oxygen may support tissue oxygenation but does not address the underlying cause of postpartum hemorrhage. Oxygen is supportive care and should not replace interventions to control bleeding.

D. Administer terbutaline: Terbutaline is a uterine relaxant used to treat preterm labor, which would worsen postpartum bleeding by inhibiting uterine contraction. It is contraindicated in cases of active postpartum hemorrhage.