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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "It will help you feel better if you talk about it." While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress.
B. "Come on out and get involved with the game the other clients are playing." Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate.
C. "I'll stay with you for a few minutes."
This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability.
D. "I'll come back when you feel like talking." This response leaves the client alone, which may
be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.
Correct Answer is B
Explanation
A. A client taking olanzapine who experiences dizziness upon standing: While dizziness is a potential side effect, it is not as immediately concerning as the symptoms in the client taking clozapine. Orthostatic hypotension is a known side effect of some antipsychotic medications, and the client may need to be assessed for orthostatic changes.
B. A client taking clozapine who has a sore throat and mild fever.
Clozapine is an atypical antipsychotic that can cause agranulocytosis, a potentially life-threatening condition characterized by a severe reduction in white blood cell count. A sore throat and mild fever can be early signs of infection, and it's crucial to evaluate the client promptly for any indications of agranulocytosis. Regular monitoring of complete blood counts is essential for clients taking clozapine.
C. A client taking risperidone who has gained 5 lb in 3 weeks: Weight gain is a side effect of many antipsychotic medications, including risperidone. While it's important to monitor weight changes, gaining 5 lb in 3 weeks is not as urgent as potential signs of agranulocytosis in the client taking clozapine.
D. A client taking chlorpromazine who is napping frequently throughout the day: Frequent napping may be related to sedation, a common side effect of chlorpromazine. While it's important to assess and address sedation, it is not as urgent as potential signs of infection or agranulocytosis in the client taking clozapine
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