The nurse continues to 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 hour.
Encourage the client to avoid napping during the day.
Minimize environmental stimuli for the client.
Weigh the client each day.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Rationale:
- Provide the client with high-calorie fluids every hour: The client has poor self-care, has not eaten for an extended period, and exhibits hyperactivity due to mania. Frequent high-calorie fluids help maintain hydration and meet increased metabolic demands. Regular intake supports nutrition and prevents further weight loss.
- Encourage the client to avoid napping during the day: Avoiding daytime napping can help regulate sleep-wake cycles and promote restorative sleep at night. Clients experiencing mania often have decreased need for sleep, so reinforcing nighttime sleep routines supports stabilization of circadian rhythms.
- Minimize environmental stimuli for the client: Clients experiencing a manic episode are easily overstimulated, which can worsen their agitation, anxiety, and psychosis. A calm, quiet environment with reduced distractions is essential for de-escalation and promoting rest.
- Weigh the client each day: Daily weight monitoring helps assess nutritional status and detect fluid imbalance, which is important given the client’s poor self-care, hyperactivity, and potential for dehydration or rapid weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Choose high-fat cheese as a meat substitute: Cheese is an animal-derived product and not part of a vegan diet. Additionally, it is high in saturated fat, which can contribute to cardiovascular risk.
B. Choose foods high in vitamin B12: Vitamin B12 is primarily found in animal products, so vegans are at risk for deficiency. Including fortified foods or supplements helps prevent anemia and neurological complications.
C. Limit intake of foods high in vitamin C: Vitamin C-rich foods are beneficial for overall health and can improve non-heme iron absorption from plant sources. There is no reason to limit these foods in a vegan diet.
D. Limit intake of nuts and legumes: Nuts and legumes are excellent plant-based sources of protein, healthy fats, and micronutrients. Restricting them would reduce the nutritional adequacy of a vegan diet.
Correct Answer is D
Explanation
Rationale:
A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.
B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.
C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.
D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.
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