1. A nurse is reinforcing teaching with a client about reducing dietary caffeine intake. The nurse should remind the client that 240 mL (8 oz) of which of the following beverages contains the least amount of caffeine?
   1. Brewed green tea
   2. Hot cocoa
   3. Instant coffee

Cola soft drink

A.a. Heart rate (98/min): A heart rate of 98/min is within the normal range for adults (60-100 bpm). This does not indicate an immediate need for further evaluation based on the provided data.

B.Blood pressure (112/88 mmHg): The blood pressure reading is within normal limits. This does not suggest an immediate concern.

C. Temperature: The client reports a low-grade fever (38.1°C or 100.5°F), which suggests an ongoing infection or inflammatory process. Further evaluation is necessary.

D.Respiratory complaint: A productive cough with blood-tinged sputum, especially in combination with symptoms such as fatigue, night sweats, and weight loss, is concerning and warrants further evaluation for possible serious conditions such as tuberculosis (TB) or other respiratory infections.

e.Oxygen saturation (98% on room air):The oxygen saturation is normal. This finding does not indicate an immediate need for further evaluation.

F.Weight loss: The client reports a significant weight loss of 26 kg (5 lbs) over the past week. Unintentional weight loss can be a concerning symptom and may indicate an underlying medical condition that requires further investigation.

G.Sputum characteristics: Blood-tinged sputum, especially with other symptoms like cough, fever, and night sweats, can be indicative of serious conditions such as TB or other respiratory infections and needs further evaluation.

H.Travel history: Recent travel to a region where certain infectious diseases are prevalent (such as TB) is a critical factor that requires further evaluation in the context of the client's symptoms.

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.