A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A.Caffeine can exacerbate symptoms of mania by increasing restlessness and irritability. Avoiding caffeine can help in managing these symptoms.

B.Lithium is a common medication used to manage manic episodes in bipolar disorder. Monitoring lithium levels is crucial to ensure the client's safety and therapeutic effectiveness.

C.Clients experiencing mania may have difficulty focusing and completing tasks, including personal hygiene. Step-by-step reminders can help the client maintain proper hygiene.

D.While social interaction can be beneficial, clients in a manic state may become overstimulated or disruptive in group settings. Individual activities are often more appropriate until the mania is better controlled.

E.Clients in a manic state may be too restless to sit down for meals. Offering finger foods allows them to eat while on the go, helping to maintain adequate nutrition.

F.Clients with mania may exhibit aggressive behaviors. Redirecting these behaviors to safer or more appropriate outlets is important for the safety of the client and others.

G.The client's vital signs indicate an increase in heart rate and blood pressure, which are important to monitor closely as they can be affected by the heightened physical activity and agitation associated with mania.

H.Lithium can cause fluid retention and weight gain. Daily weight monitoring helps detect sudden increases that may indicate fluid imbalance or early signs of lithium toxicity. It also assists in managing and adjusting treatment as needed to prevent complications.

The correct answer is choiceb. Support the client’s decision to stop the treatment.

Choice A rationale:

While discussing the decision with family can be important, the nurse’s primary responsibility is to respect and support the client’s autonomy and decision-making capacity. Encouraging the client to discuss with family is secondary to supporting their decision.

Choice B rationale:

Supporting the client’s decision to stop treatment respects their autonomy and right to make decisions about their own care.This is a fundamental principle in nursing ethics and patient-centered care.

Choice C rationale:

Discussing alternative treatment methods may be appropriate in some contexts, but in this case, the client has already made a decision to stop dialysis. The nurse should focus on supporting this decision rather than suggesting alternatives.

Choice D rationale:

Asking the facility chaplain to visit the client can be supportive, but it should not be the nurse’s primary action. The nurse should first support the client’s decision and then offer additional support services as needed.