A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Choice A reason: A space heater 5 feet from a bed is relatively safe if unobstructed, not a leading fire cause. Scientifically, heaters rank lower than smoking, as ignition requires closer flammable contact, making this less statistically significant per fire safety data.

Choice B reason: Smoking in bed is a top cause of residential fires, as embers easily ignite bedding. Scientifically, NFPA data show it’s a leading ignition source due to direct fuel contact, causing rapid flame spread, making it a critical hazard to highlight.

Choice C reason: Leaving the stove on causes kitchen fires, but smoking surpasses it in residential fatalities. Scientifically, unattended cooking ranks high, yet smoking’s bedroom context increases risk of sleeping victims, amplifying danger per fire incidence studies.

Choice D reason: Lack of smoke detectors increases fire deaths, not ignition. It’s a detection failure, not a cause. Scientifically, this affects outcomes, not initiation, making it irrelevant to identifying the leading hazard source per fire safety causation statistics.

Choice A reason: Decreased blood pressure is not a direct sign of fluid overload; it may indicate hypovolemia or shock. Fluid overload increases intravascular volume, typically raising pressure initially. This finding contradicts the excess fluid state in enteral feeding complications, where the body retains too much water, affecting other systems first.

Choice B reason: Decreased skin turgor suggests dehydration, not fluid overload. In overload, excess fluid accumulates in tissues, potentially causing edema, not poor elasticity. Enteral feeding can lead to overhydration if mismanaged, making turgor an unreliable indicator here, as it reflects fluid deficit rather than the excess seen in this scenario.

Choice C reason: Weight loss occurs with fluid loss or malnutrition, not overload. Fluid overload from enteral feedings causes rapid weight gain due to water retention. This finding opposes the expected physiology of excess fluid, where the body holds onto water, increasing mass, not shedding it as in dehydration.

Choice D reason: Crackles in the lungs indicate fluid overload, as excess fluid from enteral feedings backs up into pulmonary circulation, causing pulmonary edema. This audible sign reflects fluid escaping into alveoli, impairing gas exchange, a common complication when intake exceeds the body’s ability to excrete water effectively.