Exhibits

A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.

• Minimize environmental stimuli for the client: This is appropriate because clients experiencing acute mania are highly distractible and overstimulated. A low-stimulation environment helps reduce agitation and promotes safety.
• Weigh the client each day: Daily weights are necessary as manic clients often exhibit decreased nutritional intake and increased physical activity, placing them at risk for weight loss and dehydration.
• Provide the client with high-calorie fluids every hour: Frequent intake of calorie-dense fluids supports the client’s nutritional needs without requiring prolonged focus or interruption of hyperactive behavior.

• Encourage the client to avoid napping during the day: This is contraindicated because rest is crucial during manic episodes. Encouraging naps supports mood stabilization and prevents exacerbation of manic symptoms due to sleep deprivation.

A. Instruct the client to flex the right knee every 30 min: Flexing the knee can increase the risk of bleeding or hematoma formation at the femoral access site and is generally avoided immediately after the procedure.
B. Elevate the head of the client's bed to 45°: Elevating the head more than 30 degrees can put pressure on the femoral site and increase bleeding risk; typically, the head of the bed is kept flat or slightly elevated.
C. Change the client’s dressing 4 hr following the procedure: The initial dressing is usually kept intact for at least 24 hours unless it becomes saturated, as frequent dressing changes can disrupt the site and increase infection risk.
D. Assess the client’s peripheral pulses every 15 min: Frequent monitoring of peripheral pulses is critical to detect early signs of impaired circulation or complications such as arterial occlusion or hematoma at the catheter insertion site.