A nurse is measuring the fundal height of a client who is at 36 weeks of gestation. The client suddenly reports nausea. Which of the following actions should the nurse take?

• Pressured speech is a hallmark of mania, reflecting heightened psychomotor activity and accelerated thought processes. It often overwhelms conversation partners and makes logical communication difficult. This symptom reflects the individual’s racing mind and inability to filter or regulate their verbal output, often seen in manic episodes.
• Disorganized thought process is seen in both psychosis and mania, but manifests differently in each. In psychosis, it is often due to a breakdown in logical thinking or connection to reality. In mania, it reflects flight of ideas, rapid topic shifting, and distractibility. The presence of both symptoms indicates overlapping features.
• Excessive spending habits are consistent with manic behavior, often driven by grandiosity and poor judgment. Clients in a manic state may feel invincible or overly generous, leading them to make irrational financial decisions. These behaviors can result in significant personal or financial consequences, including debt or loss of savings.
• Hallucinations are perceptual disturbances where individuals see, hear, or feel things that are not present, primarily associated with psychosis. Auditory hallucinations, like hearing voices or unseen persons, are especially common. This indicates a loss of reality testing, which is central to diagnosing psychotic disorders.
• Lack of sleep without fatigue or distress is a key feature of mania, often preceding or accompanying a manic episode. Unlike insomnia in depression or anxiety, clients with mania may report feeling energetic and productive. The sleep deficit contributes to cognitive and emotional instability seen in manic phases.

A. Muscle weakness: Hyperkalemia disrupts normal muscle cell function by affecting membrane excitability, leading to symptoms like muscle weakness or even paralysis in severe cases. It is one of the hallmark signs of elevated potassium levels.
B. Oliguria: While hyperkalemia may be associated with renal impairment, oliguria is not a direct manifestation of high potassium but rather a possible contributing factor. It is not specific to hyperkalemia itself.
C. Hypoactive bowel sounds: Increased potassium levels typically cause hyperactivity of the gastrointestinal tract, leading to hyperactive bowel sounds and cramping, not reduced or hypoactive activity.
D. Hypertension: Hyperkalemia more commonly results in hypotension due to its effects on cardiac conduction and vasculature. Hypertension is not a typical manifestation of elevated serum potassium.