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) Utility: This principle is about producing the greatest good for the greatest number. In the case of a medication error, the focus is not on the collective good but on the individual patient's rights and well-being.
- B) Paternalism: This principle involves making decisions for others, potentially against their will, for their own good. It does not directly apply to the situation of a medication error where the patient's autonomy and right to be informed are paramount.
- C) Fidelity: This principle refers to loyalty and keeping one's promises. While important, it is secondary to the immediate need for honesty and transparency in the event of a medication error.
- D) Veracity: This principle obligates healthcare providers to tell the truth. When a medication error occurs, it is crucial to inform the patient about the mistake and the steps being taken to remedy it, making veracity the most applicable ethical principle in this scenario.

A. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus B. A client who is 1 day postpartum and has not voided in 8 hr C. A client who is 3 days postpartum and has not had a bowel movement since prior to admission D. A client who is 4 days postpartum and has lochia serosa

Correct Answer is B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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