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The nurse continues to care for the client.

Exhibits
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
 

A.

Provide the client with high-calorie fluids every hour.

B.

Encourage the client to avoid napping during the day.

C.

Minimize environmental stimuli for the client.

D.

Weigh the client each day.

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. "Your baby needs an IV because she is breathing slower than normal.": Severe dehydration is more likely to cause tachypnea rather than slower breathing, as the body attempts to compensate for metabolic acidosis.

B. "Your baby needs an IV because her heart rate is decreased.": Severe dehydration in infants usually results in tachycardia due to hypovolemia. A decreased heart rate may indicate impending cardiovascular collapse, which is a late and severe sign.

C. "Your baby needs an IV because her fontanels are bulging.": Bulging fontanels suggest increased intracranial pressure, not dehydration. Dehydration typically causes sunken fontanels due to decreased fluid volume.

D. "Your baby needs an IV because she is not producing tears.": Absence of tears during crying is a classic sign of significant dehydration in infants. This indicates reduced fluid volume and supports the need for IV therapy to restore hydration.

Correct Answer is E,A,C,B,D

Explanation

Rationale:

A. Verbally remind the staff member of the expected behaviour changes: After the initial meeting, a verbal reminder reinforces expectations and gives the staff member an opportunity to improve without formal penalties.

B. Suspend the staff member from work for several days: Suspension is used when prior interventions have not resulted in improvement. It serves as a serious consequence, giving time for reflection before returning to work.

C. Give the staff member a written warning about the behavior: A written warning follows a verbal reminder if the unprofessional behavior continues. It creates a formal record and communicates the seriousness of the issue.

D. Dismiss the staff member from employment at the facility: Termination is the final step when all other corrective measures have failed and the behavior persists, ensuring workplace standards and safety are maintained.

E. Set up a meeting to speak with the staff member about the behavior: The first action is to meet privately to discuss the observed behavior, clarify expectations, and begin the progressive discipline process in a constructive manner.

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