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.
Provide the client with high-calorie fluids every hr.
Minimize environmental stimuli for the client.
Weigh the client each day.
Encourage the client to avoid napping during the day.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
- Provide the client with high-calorie fluids every hr: Clients in manic states often experience poor nutritional intake due to hyperactivity and distractibility. Frequent, easy-to-consume high-calorie fluids help support caloric and hydration needs without requiring the client to sit for meals, making this an appropriate intervention.
- Minimize environmental stimuli for the client: Clients experiencing mania are often overstimulated and agitated due to their heightened sensitivity and rapid thought processes. A low-stimulation environment helps reduce agitation, prevent escalation, and promote safety.
- Weigh the client each day: While weight monitoring may be important in some psychiatric or medical conditions, daily weights are not a priority in the acute management of mania, particularly when the client is hyperactive, distracted, and unable to participate reliably. This could also increase agitation or preoccupation in some clients.
- Encourage the client to avoid napping during the day: Manic clients often suffer from significantly reduced sleep, which contributes to worsening symptoms. Encouraging rest and short naps would be more therapeutic than promoting wakefulness, so avoiding naps is contraindicated in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B,C"},"C":{"answers":"A,C"},"D":{"answers":"B"},"E":{"answers":"C"}}
Explanation
- Pain rating: Severe, intermittent abdominal pain where the child draws their knees to the chest and then returns to normal behavior is a classic symptom of intussusception. Neither Crohn’s disease nor appendicitis typically presents with this pattern, appendicitis pain is usually constant and worsening, while Crohn’s pain is chronic and non-episodic.
- Vomiting: Vomiting in intussusception is common and often non-bilious in early stages, aligning with the child's light-colored emesis. Vomiting also occurs in appendicitis, especially in the early stages. However, it is not a prominent or early symptom of Crohn’s disease unless obstruction is present.
- Stool: The presence of blood and mucus in the stool ("currant jelly stool") is strongly associated with intussusception and may also occur in Crohn’s disease during flares due to colonic inflammation. Appendicitis does not typically cause bloody or mucoid stools, making this finding inconsistent with that diagnosis.
- Temperature: A temperature of 37.4°C is within normal limits, appendicitis however may present with low grade fever. The absence of fever at this time limits its diagnostic value in this case.
- Abdominal findings: A distended abdomen with hypoactive bowel sounds and a palpable sausage-shaped mass in the right upper quadrant is highly indicative of intussusception. These findings are not characteristic of appendicitis, which usually involves RLQ pain, or Crohn’s, which rarely presents with a discrete palpable mass.
Correct Answer is B
Explanation
A. A client who consumes all the food from their meal tray. This is a normal finding and does not require immediate reporting to the nurse. It can be documented by the AP as part of routine care.
B. A client who has a prescription for compression stockings and did not receive them. Compression stockings are a prescribed intervention to prevent complications such as deep vein thrombosis. The nurse must be informed to ensure timely application and follow-up.
C. A client who requests to sit in the bedside chair while watching TV. This is a non-urgent and appropriate activity that does not require nursing intervention unless the client has specific mobility restrictions.
D. A client who requests assistance to use the bedside commode. Assisting with toileting is within the AP’s scope of practice and does not need to be reported unless there is an issue (e.g., change in condition, abnormal findings).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.