A nurse is caring for a client in the emergency department (ED).

Exhibits

Which of the following interventions should the nurse implement?

Stay with the client.

Place the client in a room close to the nurses' station.

Offer the client a caffeinated beverage.

Weigh the client daily.

Offer the client finger foods.

Answer and Explanation

Correct Answer : A

It is essential for the nurse to stay with the client in this situation. The client's presentation indicates manic behavior, which can be associated with bipolar disorder. Manic episodes can lead to increased energy levels, decreased need for sleep, agitation, and impulsivity. The client's refusal to sit down, pacing, and becoming agitated when asked questions all indicate potential risk to themselves or others. Staying with the client ensures their safety and the safety of others in the environment. The nurse can provide verbal support, prevent potential harm, and de-escalate the situation if needed.

Placing the client in a room close to the nurses' station might be helpful for monitoring and quick assistance, but it doesn't directly address the client's immediate agitation and need for supervision. The priority in this scenario is to ensure the client's safety, which can be achieved by staying with them.

Offering the client a caffeinated beverage is not appropriate in this situation. Caffeine can exacerbate agitation and restlessness, potentially worsening the client's symptoms. It's important to provide a calm and supportive environment instead.

Weighing the client daily is not relevant to the current situation. The client's agitation and need for supervision take precedence over routine assessments like daily weight measurement.

Offering the client finger foods is also not appropriate in this situation. The client's behavior and presentation suggest a manic episode, and their agitation indicates that they are not in a state to engage in eating. Ensuring safety and providing emotional support are the immediate priorities.

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Correct Answer is C

Explanation

Choice A rationale:
Washing the child's pillow in cold water twice monthly is not a relevant instruction for controlling allergens in asthma management. Asthma triggers are often related to airborne allergens such as dust mites, pollen, and pet dander, and focusing on pillow washing alone does not address the broader issue of allergen exposure.
Choice B rationale:
Using a humidifier in the child's bedroom can actually worsen asthma symptoms. Humidifiers can increase the humidity in the air, promoting the growth of mold and dust mites, which are common allergens that can trigger asthma symptoms. Therefore, this instruction is not appropriate for asthma management.
Choice C rationale:
This is the correct answer. Using a damp cloth to dust the child's furniture weekly is a relevant instruction for controlling allergens. Dusting with a damp cloth helps to capture and remove allergens such as dust mites, pollen, and pet dander from surfaces, reducing the child's exposure to these triggers and potentially minimizing asthma symptoms.
Choice D rationale:
Installing carpet in the child's bedroom is not recommended for asthma management. Carpets can harbor dust mites, mold, and other allergens that can exacerbate asthma symptoms. Hard flooring surfaces that can be easily cleaned and do not trap allergens are a better choice for individuals with asthma.

A. Urine osmolality 500 mOsm/kg. B. WBC 17,500/mm3. C. BUN 12 mg/dL. D. Urine specific gravity 1.014.

Correct Answer is B

Explanation

Choice A rationale:
Urine osmolality 500 mOsm/kg. Urine osmolality is a measure of urine concentration and is not a reliable indicator of infection. It reflects the kidney's ability to concentrate urine and can vary based on hydration status and other factors. An elevated urine osmolality could suggest dehydration, not necessarily infection.
Choice B rationale:
WBC 17,500/mm3. This is the correct choice. An elevated white blood cell count (WBC) is a hallmark sign of infection. The body's immune response to an infection often includes an increase in WBC count, particularly the neutrophil count. This elevation is known as leukocytosis and is a red flag for infection.
Choice C rationale:
BUN 12 mg/dL. Blood Urea Nitrogen (BUN) measures kidney function and hydration status. While an elevated BUN can indicate dehydration, it is not a specific marker for infection. BUN levels can be influenced by various factors, including diet and renal function.
Choice D rationale:
Urine specific gravity 1.014. Urine-specific gravity reflects the concentration of solutes in urine and the kidney's ability to concentrate or dilute urine. While changes in urine specific gravity can indicate dehydration or overhydration, it is not a direct indicator of infection. An infection is better detected through changes in WBC count and other clinical signs.

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A nurse is caring for a client in the emergency department (ED). Exhibits Which of the following interventions should the nurse implement?

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A nurse is caring for a client in the emergency department (ED).

Exhibits

Which of the following interventions should the nurse implement?