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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Panic. Panic-level anxiety typically involves extreme fear and severe physical symptoms such as palpitations, sweating, trembling, and a sense of impending doom. The client's reported symptoms (chest pain, headache, shortness of breath) do not align with the intense nature of panic anxiety.

B.Mild. Mild anxiety is characterized by heightened awareness and alertness. The client's symptoms and statement about his wife leaving him suggest more than mild anxiety as they indicate emotional distress beyond simple alertness.

C.Moderate. Moderate anxiety is associated with increased muscle tension, restlessness, and impaired concentration. Moderate anxiety (choice C) is characterized by increased alertness and decreased concentration but is manageable with support.

D. Severe anxiety significantly impairs daily functioning. It can cause physical symptoms such as chest pain, shortness of breath, and headaches. The client’s presentation aligns with severe anxiety, given the impact on his well-being.

A. What foods have you been eating?. B. What dose of phenelzine are you taking?. C. Do you have flu symptoms?. D. Tell me about your history of headaches.

Correct Answer is A

No explanation

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. The nurse realizes the client's findings support which level of anxiety?

Correct Answer is D

Explanation

A patient comes to the emergency department with complaints of a headache and vomiting. Upon questioning, the patient says she is taking the drug phenelzine. The nurse should continue the assessment by first asking:.

Correct Answer is A

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