A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

Provide a flexible activity schedule.

Provide high-calorie nutritional supplements.

Allow the client to eat meals alone in her room.

Allow the client to choose her clothes independently.

Answer and Explanation

The Correct Answer is B

A. This is not an appropriate action for a client experiencing acute mania. A flexible activity schedule may exacerbate symptoms by allowing too much freedom, leading to overstimulation and a lack of focus. Structured activities with clear boundaries are more effective for managing manic behaviors.

B. Providing high-calorie nutritional supplements is essential for clients in acute mania because they often exhibit hyperactivity and may neglect to eat or drink adequately. These supplements help maintain nutritional balance and prevent weight loss or dehydration during this period of heightened energy and poor self-care.

C. Allowing the client to eat meals alone in her room is not appropriate. Clients with acute mania benefit from supervised, structured environments to ensure they are eating and engaging in necessary self-care. Isolation may also increase feelings of disorganization or exacerbate symptoms.

D. Allowing the client to choose her clothes independently is not recommended during acute mania, as poor judgment and impulsivity may lead to inappropriate or excessive clothing choices. Providing simple, preselected clothing options helps reduce decision-making stress and ensures appropriate attire.

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Correct Answer is D

Explanation

A. A client who is 3 hr post Foley catheter removal and has not voided - While this may require assessment, it is not as urgent as assessing a client with potentially significant respiratory complications.

B. A client who is 3 days postoperative colectomy with a large, loose melena stool - While melena may indicate gastrointestinal bleeding, the client is not actively experiencing a respiratory issue.

C. A client who is 1 day postoperative total hip replacement with a pain level of 7 on a scale of 0 to 10 - Pain is important to address, but it is not as urgent as respiratory distress.

D. A client who is coughing up pink-tinged sputum following a bronchoscopy and lung biopsy 1 hr ago - Pink-tinged sputum may indicate bleeding from the respiratory tract, which could be a complication of the procedure and requires immediate assessment and intervention.

A. Encourage the client to gain 2.3 kg (5 lb) per week. B. Weigh the client once per week throughout hospitalization. C. Monitor the client for 1 hr after meals. D. Allow the client to choose meal times.

Correct Answer is C

Explanation

A. Encouraging the client to gain 2.3 kg (5 lb) per week may be excessive and unrealistic, potentially contributing to feelings of failure and exacerbating the client's condition.

B. Weighing the client once per week throughout hospitalization is important for monitoring weight changes, but it does not specifically address the immediate post-meal monitoring needed to prevent complications such as purging.

C. Monitoring the client for 1 hr after meals helps prevent behaviors such as purging or other forms of compensatory behaviors that may occur immediately after eating.

D. Allowing the client to choose meal times may not be appropriate as it can perpetuate disordered eating patterns. Establishing regular meal times is important for promoting consistent eating habits.

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A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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