The nurse continues to care for the client.
A nurse on the inpatient mental health unit is planning care for the client.
For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.
Encourage the client to avoid napping during the day.
Minimize environmental stimuli for the client.
Provide the client with high-calorie fluids every hr.
Weigh the client each day.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Rationale:
• Encourage the client to avoid napping during the day: A manic client has a severely diminished drive for sleep and is at risk for physical exhaustion. Any opportunity for rest or sleep, even a brief nap, should be encouraged to protect the client's physiological health.
• Minimize environmental stimuli for the client: Manic clients are highly distractible and easily overstimulated. Reducing noise, dimming lights, and providing a private room helps decrease the "manic energy" and promotes safety and calm.
• Provide the client with high-calorie fluids every hr: The client has not eaten for an extended period and exhibits poor recall of the last meal, indicating risk of malnutrition. High-calorie fluids are an appropriate intervention to ensure adequate caloric intake and hydration, thus supporting metabolic needs during the maniac episodes.
• Weigh the client each day: Daily weight monitoring helps track nutritional status and detect early signs of fluid imbalance or rapid weight loss, which can occur in clients with poor intake or hyperactivity during mania. It also assists in evaluating effectiveness of nutritional interventions. This practice provides objective data to guide care planning and assess health risks associated with inadequate intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Rationale:
A. Encourage the client to drink 3000 mL of fluid daily: This is contraindicated because the client has heart failure with signs of fluid volume excess (crackles and 3+ pitting edema). Increasing fluid intake could worsen fluid overload.
B. Review the need for the indwelling urinary catheter daily: Daily assessment of catheter necessity allows for timely removal when it is no longer needed, which significantly decreases the risk of catheter-associated urinary tract infections (CAUTIs).
C. Empty the drainage bag when it is half-full: Keeping the drainage bag from becoming overfilled prevents urine backflow into the bladder, which can introduce bacteria and increase infection risk. Regular emptying is a key preventive measure.
D. Use soap and water to provide perineal care: Proper perineal hygiene with mild soap and water helps remove bacteria and maintain skin integrity, reducing the risk of urinary tract infection, especially in incontinent clients.
E. Place the drainage bag on the bed when transporting the client: The drainage bag should always remain below the level of the bladder and off the bed to prevent backflow of urine, which can introduce bacteria and increase infection risk.
F. Change the indwelling urinary catheter tubing every 3 days: Routine scheduled tubing changes are not recommended, as unnecessary manipulation of the system can increase infection risk. Tubing should only be changed when clinically indicated (e.g., contamination, obstruction).
Correct Answer is D
Explanation
A. Ensure that the health care provider has consulted with another team member: While consultation may be part of ethical decision-making, it is not the primary action the nurse should take when a comatose client requires consent. The priority is confirming that informed consent is obtained from the appropriate decision-maker.
B. Ensure that the client's 16-year-old child supports the provider's decision for surgery: Minors cannot legally provide consent for medical procedures. The nurse should focus on the legal health care surrogate or guardian rather than the opinion of a minor child.
C. Determine if the procedure is medically necessary for the client: Assessing medical necessity is the provider’s responsibility. The nurse’s role is to advocate for the client by ensuring informed consent is obtained and the surrogate understands the procedure, risks, and benefits.
D. Determine if the health care surrogate understands the risks and benefits of the procedure: The nurse should confirm that the health care surrogate has received adequate information and understands the risks, benefits, and alternatives to the procedure. This ensures ethical and legal consent is obtained for a client unable to make decisions.
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