A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following goals should the nurse include?
Client sleeps 6 hr each night.
Client has a 0.9 kg (2 lb) weight loss from previous week.
Client has an increase in urine specific gravity
Client gives personal gifts to other clients.
The Correct Answer is A
Choice A rationale:
During the manic phase of bipolar disorder, sleep disturbances are common. Setting a goal for the client to achieve an appropriate amount of sleep can help stabilize their mood and reduce the intensity of manic symptoms.
Choice B rationale:
A weight loss goal might be more appropriate during the depressive phase, as manic episodes are often associated with increased energy and decreased appetite.
Choice C rationale:
Increased urine specific gravity is not a specific goal for managing the manic phase of bipolar disorder.
Choice D rationale:
Giving personal gifts to other clients might be a manifestation of the client's manic behavior and is not a goal to strive for.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Correct Answer is C
Explanation
Choice A rationale:
The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.
Choice B rationale:
The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.
Choice C rationale:
The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.
Choice D rationale:
The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.
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