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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Presence of cough

Absence of gag reflex

Respiratory rate of 6 breaths per minute

Urine output 90 mL/hour

Heart rate 70 beats per minute

Capillary refill less than 3 seconds

Answer and Explanation

Correct Answer : B,C

A. The presence of a cough is expected as a protective reflex and does not delay transfer.

B. The absence of a gag reflex increases the risk of aspiration, delaying safe transfer.

C. A respiratory rate of 6 breaths per minute indicates respiratory depression, which requires immediate intervention.

D. Urine output of 90 mL/hour is within the expected range and does not delay transfer.

E. A heart rate of 70 beats per minute is normal and not a contraindication for transfer.

F. Capillary refill less than 3 seconds is normal and does not delay the transfer.

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Correct Answer is C

Explanation

A. Lorazepam is a benzodiazepine used for anxiety and agitation, but it is not typically used to treat mania.

B. Fluvastatin is a statin medication used to manage cholesterol, not a treatment for mania.

C. Carbamazepine is a mood stabilizer commonly used to treat mania in clients with bipolar disorder, helping to reduce the severity of manic episodes.

D. Propranolol is a beta-blocker used to manage symptoms of anxiety, but it is not used to treat the manic phase of bipolar disorder.

A. The client reports that voices are telling him to write a novel. B. The client is dressed in all black C. The client responds to questions with disorganized speech. D. The client's spouse reports that client has recently gained weight.

Correct Answer is C

Explanation

A. Hearing voices could indicate psychosis, which is not specifically linked to acute mania in bipolar disorder. Mania may involve delusions or grandiosity but not auditory hallucinations.

B. Dressing in all black is not specific to acute mania and could be related to personal style or another mood state.

C. Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. The individual may exhibit flight of ideas, rapid speech, or incoherent thoughts.

D. Weight gain is more commonly associated with depression or medication side effects, not acute mania.

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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)

Nursing Test Bank

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Correct Answer is C

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The nurse is preparing to transfer a client from the post-anesthesia care unit (PACU). Which assessment findings would delay the transfer of the client? (Select All that Apply.)