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 A
Explanation
A. Implement firm but flexible boundaries in their relationship: Establishing boundaries helps both the client and adult child adapt to new caregiving roles while maintaining mutual respect and autonomy. Flexibility allows for adjustments as the client’s needs change, reducing role strain and promoting a healthy family dynamic.
B. Encourage authoritative communication from the adult child: While clear communication is important, an authoritative style may be perceived as controlling and can create tension. Collaborative, respectful communication is more effective in supporting role adjustment and maintaining family harmony.
C. Decrease socialization with extended relatives until roles are identified: Limiting social interactions is unnecessary and may increase isolation or stress. Maintaining connections with extended family can provide emotional support and resources during the transition.
D. Minimize open discussion regarding the changes to avoid embarrassment: Avoiding discussion about changes can lead to misunderstandings, unmet needs, and emotional strain. Open, honest communication helps clarify expectations, reduce conflict, and facilitate adjustment to new roles.
Correct Answer is ["A","B","C","E"]
Explanation
A. The client takes 2 short naps during the day: The ability to rest indicates decreased hyperactivity and improved regulation of sleep-wake cycles, reflecting early stabilization of manic symptoms.
B. The client engages in quiet activities in their room: Participation in calm, structured activities demonstrates reduced agitation and impulsivity, suggesting improvement in mood stability and ability to focus.
C. The client slept 5 hr the previous night: Improved sleep duration is a positive sign, as insomnia and decreased need for sleep are hallmark symptoms of mania. Achieving rest indicates partial symptom resolution.
D. The client appears to listen to unseen others: Continued auditory hallucinations indicate persistent psychotic features and do not represent improvement. These symptoms require ongoing monitoring and treatment.
E. The client consumes 8 oz of high-calorie fluids each hour: Adequate fluid and calorie intake reflects improved self-care and nutrition, which are often compromised during acute manic episodes. This is a positive indicator of functional recovery.
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