A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?

Place the client in seclusion when he exhibits signs of anxiety.

Encourage the client to spend time in the dayroom.

Encourage the client to take frequent rest periods.

Withdraw the client's TV privileges if he does not attend group therapy.

Answer and Explanation

The Correct Answer is C

A.   Incorrect. Placing the client in seclusion is not an appropriate intervention for managing mania.
B.   Incorrect. Encouraging the client to spend time in the dayroom may exacerbate symptoms of mania by providing more stimulation.
C.   Correct. Encouraging the client to take frequent rest periods helps prevent overactivity and exhaustion, common in manic episodes.
D.   Incorrect. Withdrawing privileges are not directly related to managing manic symptoms and may not be therapeutic.

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Correct Answer is B

Explanation

A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.

B. Correct. Encouraging collaboration empowers the nurses to work together and find common ground in making assignments.

C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.

D. Incorrect. Asking each nurse to take turns making the assignments might not resolve the perceived favoritism and could create further tension.

A. Current medications B. Temperature C. Hemoglobin and hematocrit D. WBC count E. Blood pressure F. Respiratory rate G. Stool results H. Heart rate

Correct Answer is ["A","C","E","G","H"]

Explanation

The correct answer is:Choices c, e, g, h, and a.

Choice A rationale (Current medications): The client is taking Ibuprofen 800 mg three times daily as needed for arthritis pain.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation, ulcers, and bleeding, especially when used at high doses or for a prolonged period 1 2. Given the client’s symptoms of abdominal pain and a history of dark, tarry stool, the medication could be contributing to these symptoms and warrants further investigation.

Choice B rationale (Temperature): The client’s temperature is 37.5° C (99.5° F), which is within the normal range 3 4. Therefore, it does not require immediate follow-up.

Choice C rationale (Hemoglobin and hematocrit): The client’s hemoglobin level is 9.1 g/dL, which is lower than the normal range of about 13.0 to 17.5 g/dL for adult males and 12.0 to 15.5 g/dL for adult females 5 6.The client’s hematocrit is 27%, which is also lower than the normal range of about 38.3% to 48.6% for adult males and 35.5% to 44.9% for adult females 7.Low hemoglobin and hematocrit levels can indicate anemia, which could explain the client’s reported fatigue and pale mucous membranes 8 7.

Choice D rationale (WBC count): The client’s WBC count is 6,700/mm3, which falls within the normal range of about 4,500 to 11,000 WBCs per microliter 9 10. Therefore, it does not require immediate follow-up.

Choice E rationale (Blood pressure): The client’s blood pressure is 90/50 mm Hg, which is lower than the normal range 11. Low blood pressure can cause symptoms such as dizziness, fainting, or blurred vision and requires immediate follow-up.

Choice F rationale (Respiratory rate): The client’s respiratory rate is 18 breaths per minute, which is within the normal range for adults of about 12 to 20 breaths per minute 4 12. Therefore, it does not require immediate follow-up.

Choice G rationale (Stool results): The client’s stool tested positive for blood (Hemoccult positive), which could indicate gastrointestinal bleeding 13. This finding, combined with the client’s reported abdominal pain and history of dark, tarry stool, requires immediate follow-up.

Choice H rationale (Heart rate): The client’s heart rate is 118 beats per minute, which is higher than the normal range for adults of about 60 to 100 beats per minute 14.A high heart rate, or tachycardia, can be caused by factors such as stress, anxiety, physical exertion, dehydration, and certain medical conditions 14. Given the client’s reported symptoms and medical history, this finding warrants immediate follow-up.

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A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E","G","H"]

Explanation

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A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?