A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of the following is an expected finding?

A. Providing a flexible activity schedule allows the client to engage in activities that match their energy level and interests, promoting a sense of control and reducing agitation during acute

mania.

B. High-calorie nutritional supplements are not typically indicated solely based on the diagnosis of acute mania. Nutritional needs should be assessed, but providing high-calorie supplements

may not address the underlying issues associated with mania.

C. Allowing the client to eat meals alone in her room may not be safe or therapeutic during acute mania, as supervision during meals can ensure adequate nutrition and prevent potential harm or

inappropriate behaviors.

D. While promoting independence is important, allowing the client to choose her clothes independently may not be appropriate during acute mania, as it could result in wearing

inappropriate attire or exacerbate impulsivity.

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.