A nurse is caring for a client who has bipolar disorder and is experiencing mania.
Which of the following actions should the nurse take?
Frequently remind the client of the expectations for her behavior.
Encourage the client to participate in a group activity in the dayroom.
Allow the client to pick her own choice of clothing.
Encourage the client to increase physical activity during the day.
The Correct Answer is A
Answer: A. Frequently remind the client of the expectations for her behavior.
Rationale:
A) Frequently remind the client of the expectations for her behavior:
Clients experiencing mania may have difficulty maintaining appropriate behavior due to their heightened energy levels and impulsivity. Frequently reminding them of behavioral expectations helps provide structure and boundaries, which can promote a safer and more controlled environment.
B) Encourage the client to participate in a group activity in the dayroom:
While social interaction can be beneficial, clients in a manic state might be overly stimulated by group activities. This can exacerbate their symptoms, leading to increased agitation or disruptive behavior. It's often more appropriate to provide a calm and low-stimulation environment.
C) Allow the client to pick her own choice of clothing:
Allowing a manic client to choose their own clothing can lead to choices that are inappropriate for the setting or the weather, as judgment may be impaired during mania. Providing guidance in clothing choices can help ensure the client is dressed suitably and safely.
D) Encourage the client to increase physical activity during the day:
While physical activity is generally beneficial, clients in a manic state may already be overly active and may not need encouragement to increase their activity. Overexertion can lead to exhaustion and further exacerbate manic symptoms. It is often more beneficial to encourage activities that promote relaxation and calmness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B. Stiff posture
Rationale:
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.
Correct Answer is D
Explanation
The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.
A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.
The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.
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