A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.).
Discourage the client from taking a nap during the day.
Weigh the client every 3 to 4 days.
Maintain an environment with low stimuli.
Offer finger foods to the client every 2 hr.
Monitor vital signs every 1 to 2 hr throughout the day.
Correct Answer : C,D,E
Correct answers: C, D, E
Choice A rationale:
While a consistent sleep schedule is important in the long term, a short nap during the day might be helpful for someone experiencing mania to prevent complete exhaustion, which can worsen symptoms.
Choice B rationale:
Weighing the client every 3 to 4 days (Choice B) might not be as crucial as the other options provided. While changes in weight can occur during mania, this intervention may not be as directly related to managing the acute symptoms of mania as other interventions.
Choice C rationale:
Maintaining an environment with low stimuli (Choice C) is essential during a manic episode. Clients with mania often experience heightened sensory sensitivity, and reducing environmental stimuli can help decrease agitation and promote a more stable mood.
Choice D rationale:
A client in a manic episode has increased caloric needs due to constant physical activity but may be unable to sit down for regular meals. Providing finger foods allows them to eat while remaining active.
Choice E rationale:
Mania can cause physiological changes like increased heart rate, blood pressure, and body temperature. Frequent monitoring helps detect potential complications and guide treatment decisions.
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Naxlex Comprehensive Predictor Exams
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