A nurse is reinforcing teaching with a caregiver of a 2-month-old infant about developmentally appropriate toys. which of the following toys should the nurse include in the teaching?

A) Irregular heart rate: An irregular heart rate is a key manifestation of hyperkalemia. Elevated potassium levels can interfere with the normal electrical activity of the heart, leading to arrhythmias, which can cause an irregular heart rate. In severe cases, hyperkalemia can lead to life-threatening cardiac events such as ventricular fibrillation or asystole.

B) Dry mucous membrane: Dry mucous membranes are more commonly associated with dehydration, not hyperkalemia. Dehydration can cause fluid volume depletion, which leads to dry mouth and other signs of insufficient hydration. While renal failure can lead to fluid balance issues, dry mucous membranes are not typically linked to elevated potassium levels.

C) Trousseau's sign: Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia. It is a spasm of the hand and wrist that occurs when a blood pressure cuff is inflated above systolic pressure for several minutes. This sign suggests low calcium levels, and while calcium imbalance can occur in renal failure, it is unrelated to hyperkalemia.

D) Hyperactive reflexes: Hyperactive reflexes are more commonly associated with conditions like hypocalcemia, rather than hyperkalemia. In hyperkalemia, the typical findings include muscle weakness or paralysis due to the effect of potassium on muscle and nerve function, but hyperactive reflexes would not be expected.

A) Allow the client to have 1 hour of time alone in their room:
Allowing the client to be alone in their room may not be the best option when they are pacing and wringing their hands, which may indicate anxiety or distress. Rather than isolating them, it is more appropriate to offer support and engage with the client to address the potential underlying anxiety or agitation. Time alone may escalate the feelings of distress rather than provide relief.

B) Use short, simple sentences when speaking with the client:
Using short, simple sentences is an appropriate action when interacting with a client who is pacing and wringing their hands, as this behavior can be indicative of heightened anxiety or agitation. Simple communication reduces confusion and minimizes the cognitive load on the client, helping to keep the interaction clear and calm. It can also help the nurse better assess the client’s feelings and needs in a way that feels less overwhelming to the client.

C) Ask the client if they would like to watch television:
While offering the option of watching television could be an attempt to distract or comfort the client, it does not directly address the potential underlying anxiety or distress the client may be experiencing. It is important to first assess and manage the client’s emotional state before offering distractions like television, which may not effectively address the root of the issue.

D) Move the client to a table where other clients are playing cards:
Moving the client to a group activity may not be the best approach in this situation. The client is demonstrating signs of anxiety or agitation, and suddenly introducing them to a group environment might be overwhelming and could increase their distress. It is more appropriate to first engage the client in a calm, one-on-one interaction using simple communication, and then consider group activities if the client appears ready for them.