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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 hr.

B.

Minimize environmental stimuli for the client.

C.

Weigh the client each day.

D.

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.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

  • Prolonged rupture of membranes: Rupture of membranes lasting longer than 18 hours increases the risk of ascending bacterial infection, leading to conditions such as endometritis. This is a known risk factor for postpartum infection, especially following cesarean delivery.
  • Polyhydramnios: An excessive amount of amniotic fluid overdistends the uterus, which can impair its ability to contract effectively postpartum, making uterine atony more likely. Atony can lead to increased bleeding or retained lochia.
  • Prenatal anemia: While not directly causing infection, anemia impairs immune function, increasing a person's susceptibility to postpartum infections. It can also worsen recovery from infections or surgical wounds.
  • High parity: Multiple prior pregnancies stretch the uterus over time, reducing myometrial tone, which predisposes to uterine atony. This makes it harder for the uterus to contract adequately after delivery, increasing the risk for hemorrhage or subinvolution.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

  • Tocolytic medication: Tocolytics are used to suppress preterm labor, which is not applicable for this postpartum client. There is no indication of uterine contractions needing suppression.
  • Intravenous antibiotic: The client exhibits signs of postpartum endometritis—including fever, uterine tenderness, foul-smelling lochia, and a very high WBC count (33,000/mm³). These findings strongly support the need for IV antibiotics to treat the infection.
  • Intrauterine tamponade balloon: This device is used for managing postpartum hemorrhage, which is not present in this case. The client’s lochia is moderate, not excessive, and her uterus is responding to massage.
  • Kleihauer-Betke test: This test is used to detect fetal-to-maternal hemorrhage, particularly in Rh-negative mothers after trauma or potential placental separation. It is not relevant in the context of postpartum infection.
  • Increase in daily fluid intake: The client is febrile and shows signs of systemic infection. Increased fluids support hydration, promote recovery, and help manage the effects of fever and infection, making this an appropriate supportive measure.

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