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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hypotension occurs because hypermagnesemia causes vasodilation, which lowers blood pressure. Magnesium acts as a smooth muscle relaxant, decreasing vascular resistance and contributing to hypotension. This is a common clinical finding when magnesium levels exceed the normal range.
B. Tachycardia is not expected with hypermagnesemia. Elevated magnesium levels depress the heart's electrical activity, leading to bradycardia (slow heart rate) instead of tachycardia.
C. Muscle cramps are typically associated with hypomagnesemia, which increases neuromuscular excitability. In hypermagnesemia, neuromuscular function is suppressed, leading to muscle weakness rather than cramps.
D. Hyperreflexia is a symptom of hypomagnesemia, not hypermagnesemia. In hypermagnesemia, neuromuscular activity is depressed, resulting in diminished or absent deep tendon reflexes
Correct Answer is D
Explanation
A. Insisting the client use direct eye contact may be intimidating or uncomfortable for the client, especially in a mental health setting where individuals may have varying levels of comfort with eye contact.
B. Seating the client at such a distance may create a physical barrier and hinder effective communication between the nurse and the client.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially during a sensitive interview.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and facilitates a sense of closeness and engagement in the conversation, which can help build rapport and trust.
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