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.

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.

Answer and Explanation

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

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Diphenhydramine. Urticaria (hives) is a common allergic reaction often caused by medications like antibiotics. Diphenhydramine, an antihistamine, is used to treat allergic reactions by blocking histamine receptors, reducing itching, swelling, and rash.
B. Hydralazine. This is an antihypertensive medication used to treat high blood pressure, not allergic reactions. It has no effect on histamine or allergic symptoms.
C. Naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose. It does not treat allergic reactions like urticaria unless the cause is opioid-induced (which is not indicated here).
D. Protamine. Protamine is used to reverse the effects of heparin. It has no role in treating allergic reactions to antibiotics.

A. Administer packed RBCS. B. Obtain a specimen for ABG analysis. C. Place a large-bore IV catheter in an upper extremity. D. Insert an indwelling urinary catheter.

Correct Answer is C

Explanation

A. Administer packed RBCs. While blood transfusion may be urgently needed for hemorrhagic shock, it cannot be initiated until vascular access is established. It is important, but not the first step.
B. Obtain a specimen for ABG analysis. Arterial blood gases can provide valuable information about respiratory and metabolic status, but they are not the top priority in an unstable trauma patient.
C. Place a large-bore IV catheter in an upper extremity. Establishing IV access is the priority in trauma care, as it allows for rapid fluid resuscitation and medication administration. This intervention supports all subsequent emergency treatments.
D. Insert an indwelling urinary catheter. A catheter may be necessary for monitoring urine output as a sign of perfusion, but this is not the first action in a trauma situation where immediate stabilization is the priority.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urticaria following administration of an antibiotic. Which of the following medications should the nurse prepare to administer?

Correct Answer is A

Explanation

A nurse in an emergency department is planning care for a client who has abdominal trauma from a motor-vehicle crash. Which of the following provider prescriptions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

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A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?

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.