A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?
Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently.
Play loud music for the client in her room.
Engage the client in a small group activity.
Instruct the client to avoid napping during the day.
The Correct Answer is A
A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently.
Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode.
B. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment.
C. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania.
D. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Grandiosity.
Grandiosity is a symptom commonly seen in the manic phase of bipolar disorder. It involves an inflated sense of self-importance, unrealistic beliefs in one's abilities, and a perception of being involved in activities that are revolutionary or of great significance. In this scenario, the client's statement about revolutionizing the industry reflects grandiosity.
B. Clang associations involve the association of words based on sound rather than meaning and are often seen in individuals with thought disorders.
C. Flight of ideas refers to a rapid flow of thoughts, often manifested by speech that is difficult to interrupt, with topics changing rapidly.
D. Confabulation is the creation of false or distorted memories without the intention to deceive. It is not a characteristic behavior of mania in bipolar disorder.
Correct Answer is ["A","B","D"]
Explanation
A. Sodium level: Correct. Sodium imbalances can have serious consequences, including neurological symptoms. Hyponatremia is a common electrolyte imbalance seen in anorexia nervosa.
B. Blood pressure: Correct. Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa.
C. Respiratory rate: Not selected. While monitoring respiratory rate is important, the client's pallor and capillary refill suggest potential issues with peripheral perfusion, making capillary refill more urgent.
D. Capillary refill: Correct. Prolonged capillary refill time is a measure of peripheral perfusion and may indicate poor tissue perfusion, requiring immediate attention.
E. Glucose level: Not selected. While monitoring glucose levels is important, hypoglycemia might not be an immediate concern in this scenario. The client's neurological symptoms may be more related to electrolyte imbalances.
F. Phosphate level: Not selected. Monitoring phosphate levels is important, but severe abnormalities may not require immediate follow-up unless other critical issues are addressed first.
G. Magnesium level: Not selected. Magnesium imbalances are significant but may not require immediate follow-up unless severe abnormalities are noted.
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