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 C
Explanation
A. Provide the client with a walker: While a walker may be used during ambulation, ensuring the client's physiological readiness for ambulation takes precedence.
B. Premedicate the client with the prescribed analgesic: While pain management is important for comfort during ambulation, premedication may not be necessary for all clients and should be based on individual assessment.
C. Obtain the client's vital signs and oximetry prior to ambulation: This intervention allows the nurse to assess the client's physiological status and ensure stability before initiating ambulation, reducing the risk of complications.
D. Reinforce the client's surgical dressing: While maintaining the integrity of the surgical
incision is important, reinforcing the dressing alone does not ensure the client's readiness for ambulation.
Correct Answer is C
Explanation
A. Varicella-zoster (chickenpox) requires airborne precautions due to its transmission via respiratory droplets or aerosols.
B. Vancomycin-resistant enterococcus (VRE) is typically transmitted through direct contact with contaminated surfaces or equipment and does not require droplet precautions.
C. Pertussis (whooping cough) is transmitted via respiratory droplets and requires droplet precautions to prevent transmission to others.
D. Rotavirus is primarily transmitted through the fecal-oral route and requires contact precautions, not droplet precautions.
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