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
A. Hypotension: Methamphetamines are central nervous system stimulants that typically cause hypertension and tachycardia due to increased sympathetic activity, rather than low blood pressure.
B. Weight loss: Methamphetamines suppress appetite and increase metabolism, which can lead to significant weight loss. This is a common adverse effect associated with chronic use.
C. Somnolence: Stimulant effects of methamphetamines generally cause insomnia and hyperactivity rather than excessive sleepiness. Somnolence is not a typical adverse effect.
D. Lethargy: Methamphetamine use initially produces energy and euphoria. Lethargy may occur only during withdrawal, not as a direct adverse effect of active use.
Correct Answer is D
Explanation
Rationale:
A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.
B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.
C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.
D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.
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