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A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania.
Select the 3 prescriptions that the nurse should anticipate for this client.

Administer 0.9% sodium chloride IV.

Administer IV flumazenil.

Prepare the client for intubation.

Begin chest compressions

Administer IV naloxone.

Administer activated charcoal.

Prepare the client for electroconvulsive therapy (ECT).

Answer and Explanation

Correct Answer : A,E,G

The correct answer/s is Choice/s A, E, and G.

Choice A rationale: Administering 0.9% sodium chloride IV is a common practice in emergency departments to ensure the patient is well-hydrated. This is particularly important for patients experiencing acute mania, as they may have neglected their physical health, including hydration, during their manic episode.

Choice B rationale: Flumazenil is an antagonist for benzodiazepines and is typically used to reverse the sedative effects of benzodiazepines. It is not typically used in the treatment of bipolar disorder or acute mania.

Choice C rationale: Preparing the client for intubation is usually reserved for situations where the patient is unable to maintain their own airway or adequate ventilation. This is not typically necessary in cases of acute mania unless there are other complicating factors.

Choice D rationale: Beginning chest compressions is a response to cardiac arrest. There is no indication in the that the patient is experiencing cardiac arrest, so this would not be a typical anticipation for a patient experiencing acute mania.

Choice E rationale: Administering IV naloxone is done in cases of suspected opioid overdose. While it’s not directly related to treating acute mania, it’s possible that the patient could have comorbid substance use issues, given the high rate of comorbidity between bipolar disorder and substance use disorders.

Choice F rationale: Administering activated charcoal is done in cases of certain types of poisoning or drug overdose. It is not typically used in the treatment of bipolar disorder or acute mania.

Choice G rationale: Preparing the client for electroconvulsive therapy (ECT) could be an appropriate anticipation for a patient experiencing acute mania. ECT is considered a highly effective treatment for severe mania, particularly when other treatments have failed or when rapid stabilization is required.

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Correct Answer is C

Explanation

Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.

However, it’s not the most critical vital sign to address first in this scenario.

Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.

However, it’s not the most immediate concern compared to other vital signs.

Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.

Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.

Therefore, it should be addressed first.

Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.

However, it’s not the most immediate concern in this scenario.

In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.

A. Hypomagnesemia B. Renal failure C. Heart failure D. Hyperthyroidism.

Correct Answer is A

Explanation

Choice A rationale:

The client’s reported behavior of using laxatives and inducing vomiting after eating can lead to a condition known as hypomagnesemia. Hypomagnesemia is a condition characterized by low levels of magnesium in the blood. This condition can be caused by poor intake, excessive loss, or movement of magnesium from the blood into less accessible locations. The use of laxatives can lead to excessive loss of magnesium through increased bowel movements. Similarly, self-induced vomiting can also result in a loss of magnesium. Therefore, the client’s behavior puts them at risk for developing hypomagnesemia.

Choice B rationale:

Renal failure, also known as kidney failure, occurs when the kidneys lose their ability to filter waste products from the blood. While the use of laxatives and self-induced vomiting can lead to dehydration, which can strain the kidneys, these behaviors are not directly associated with renal failure. Therefore, while it’s possible for the client to develop kidney problems, it’s less likely compared to hypomagnesemia.

Choice C rationale:

Heart failure occurs when the heart muscle doesn’t pump blood as well as it should. This condition can cause symptoms like shortness of breath, swelling, fatigue, and other symptoms. While severe electrolyte imbalances, such as those that might result from the use of laxatives and self-induced vomiting, can affect heart function, they would typically result in arrhythmias (irregular heartbeats) rather than heart failure. Therefore, it’s less likely for the client to develop heart failure based on the behaviors described.

Choice D rationale:

Hyperthyroidism is a condition where the thyroid gland produces and releases too much thyroid hormone. This condition can cause symptoms like rapid heartbeat, weight loss, and anxiety. The client’s behaviors of using laxatives and inducing vomiting after eating do not directly influence the production of thyroid hormones. Therefore, it’s less likely for the client to develop hyperthyroidism based on the behaviors described.

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A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania. Select the 3 prescriptions that the nurse should anticipate for this client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health unit is admitting a female client who has anorexia nervosa. The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's:

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania.
Select the 3 prescriptions that the nurse should anticipate for this client.