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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Requesting an appointment to discuss depression is an indication that the client is seeking help, which is a positive step. It does not necessarily indicate an immediate risk of suicide.

B. Stating that they are stopping their medication raises concerns about treatment compliance, but it does not provide a clear indication of suicidal intent. It is important to assess the reasons for discontinuing medication and address any concerns.

C. Sleeping 12 hours a day can be a symptom of depression, but it does not necessarily indicate an immediate risk of suicide. It is crucial to assess the client's overall mental health and functioning.

D. A client who is giving away their possessions.
Giving away possessions can be a warning sign of suicidal intent. This behavior may indicate that the individual is preparing for the possibility of not needing those belongings in the future. It is crucial for the nurse to assess and intervene promptly if a client is exhibiting signs of suicidality.

A. Sodium level B. Phosphate level C. Magnesium level D. Respiratory rate E. capillary refill F. Blood pressure G. Glucose level

Correct Answer is ["A","D","E","F","G"]

Explanation

A. Sodium level:
Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures.

B. Phosphate level:
While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical.

C. Magnesium level:
Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance.

D. Respiratory rate:
Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function.

E. Capillary refill:
Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns.

F. Blood pressure:
Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being.

G. Glucose level:
Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client

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A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is ["A","D","E","F","G"]

Explanation

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