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 B
Explanation
A. "Morphine 3.0 mg sub q every 4 hr PRN for pain." Including a trailing zero (3.0 mg) is considered unsafe and is discouraged in medication documentation. It increases the risk of a tenfold overdose if the decimal is missed.
B. "Morphine 3 mg subcutaneous every 4 hr PRN for pain." This entry uses the correct dosage format without a trailing zero, the full term "subcutaneous" instead of abbreviations, and proper medical terminology. It adheres to safe documentation practices as per The Joint Commission guidelines.
C. "Morphine 3 mg SC q 4 hr PRN for pain." The abbreviation “SC” is considered unsafe and prone to misinterpretation. Also, "q" for "every" is discouraged in clinical documentation due to potential misreading and error.
D. "Morphine 3 mg SQ every 4 hr PRN for pain." The abbreviation “SQ” can be misinterpreted or mistaken for “5 every” or other terms. Safe practice requires spelling out “subcutaneous” to prevent errors in medication administration.
Correct Answer is C
Explanation
A. Refer the family to a chronic pain support group. While helpful, this is a later step in the care plan. The nurse must first assess the child's specific condition and patterns of pain.
B. Set up an appointment with the school nurse. This is a supportive measure but not the priority. The nurse must gather more information before involving school personnel.
C. Review the child's electronic pain diary. This is the first action because it allows the nurse to assess the frequency, triggers, severity, and duration of the migraines. Understanding the child's pain pattern is essential for effective treatment planning.
D. Request a change in medication from the provider. This may be necessary, but the nurse should first gather complete data on the child's symptoms and current response to treatment before suggesting changes to the medication regimen.
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