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 D
Explanation
A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.
Correct Answer is ["B","C","D"]
Explanation
A. "Blurred vision is an expected adverse effect of this medication." Blurred vision is not a common or expected adverse effect of lithium. If this occurs, it may indicate toxicity or another underlying issue and should be reported. It is not part of routine education for expected side effects.
B. "This medication can cause weight gain." This is true. Weight gain is a known long-term adverse effect of lithium therapy and should be discussed with the client and family as part of monitoring and lifestyle considerations during treatment.
C. "This medication can cause nausea and drowsiness." These are common initial side effects when starting lithium and usually subside over time. Clients should be aware of these effects so they can differentiate between expected reactions and signs of toxicity.
D. "It will take at least a week before this medication reaches a therapeutic level." Correct. Lithium takes 7–14 days to reach therapeutic plasma levels, so clients may not experience symptom relief immediately. During this period, supportive care and safety monitoring are essential.
E. "You will be placed on a low-sodium diet while taking this medication." This is incorrect. Lithium has a narrow therapeutic index, and sodium levels affect lithium levels. A low-sodium diet can increase the risk of lithium toxicity, so clients should maintain a consistent sodium intake, not reduce it.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.