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The nurse is reviewing the medical records of the client who is exhibiting mania. Which of the following actions should the nurse take? Select all that apply.

Vital Signs 0800:

Heart rate 110/min Respiratory rate 20/min

Blood pressure 132/80 mm Hg Temperature 37.2° C (99° F)

1100:

Heart rate 120/min

Respiratory rate 24/min

Blood pressure 149/90 mm Hg Temperature 37.2° C (98.9° F)

Encourage the client to avoid caffeine.

Report lithium level to the provider.

Provide step-by-step reminders regarding hygiene.

Involve the client in group activities.

Encourage the client to eat finger foods frequently.

Redirect aggressive behaviors

Monitor the blood pressure and heart rate every 4 hr.

Weigh the client daily.

Answer and Explanation

Correct Answer : A,B,C,E,F,G,H

A. Caffeine can exacerbate symptoms of mania by increasing restlessness and irritability. Avoiding caffeine can help in managing these symptoms.

B. Lithium is a common medication used to manage manic episodes in bipolar disorder. Monitoring lithium levels is crucial to ensure the client's safety and therapeutic effectiveness.

C. Clients experiencing mania may have difficulty focusing and completing tasks, including personal hygiene. Step-by-step reminders can help the client maintain proper hygiene.

D. While social interaction can be beneficial, clients in a manic state may become overstimulated or disruptive in group settings. Individual activities are often more appropriate until the mania is better controlled.

E. Clients in a manic state may be too restless to sit down for meals. Offering finger foods allows them to eat while on the go, helping to maintain adequate nutrition.

F. Clients with mania may exhibit aggressive behaviors. Redirecting these behaviors to safer or more appropriate outlets is important for the safety of the client and others.

G. The client's vital signs indicate an increase in heart rate and blood pressure, which are important to monitor closely as they can be affected by the heightened physical activity and agitation associated with mania.

H. Lithium can cause fluid retention and weight gain. Daily weight monitoring helps detect sudden increases that may indicate fluid imbalance or early signs of lithium toxicity. It also assists in managing and adjusting treatment as needed to prevent complications.

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Correct Answer is C

Explanation

Restlessness can be a common manifestation of pain. When a client is experiencing unrelieved pain, they may exhibit restlessness, which can include fidgeting, pacing, or frequent position changes in an attempt to find relief. Restlessness may also be accompanied by increased heart rate, elevated blood pressure, and changes in respiratory rate.

Difficulty swallowing (dysphagia) is not a specific indicator of unrelieved pain in a client with a spinal epidural for a herniated disc. Difficulty swallowing can be caused by various factors, including anatomical abnormalities, neurological conditions, or muscle dysfunction.

Constipation is not a specific indicator of unrelieved pain in this scenario. Constipation can be a side effect of certain medications, including opioids that are commonly used to manage pain.

However, it is not an exclusive indicator of unrelieved pain and can be managed through interventions such as adequate hydration, fiber intake, and appropriate bowel regimen.

Urinary retention is not a specific indicator of unrelieved pain in this context. It can be associated with several factors, including the use of certain medications, urinary tract infections, or neurological conditions. Urinary retention may require assessment and management but does not necessarily indicate unrelieved pain.

A. 16 lb B. 32 lb C. 24 lb D. 8 lb

Correct Answer is A

Explanation

A. Correct. For a client with a pre-pregnancy BMI of 30.5 (considered obese., an acceptable weight gain during pregnancy is typically around 1120 pounds (59 kg., making 16 pounds an appropriate option within this range.
B. Incorrect. A weight gain of 32 pounds would be considered excessive for a client with a pre-pregnancy BMI of 30.5.
C. Incorrect. A weight gain of 24 pounds might still fall within an acceptable range, but for a client with a pre-pregnancy BMI of 30.5, a weight gain of 16 pounds is a more appropriate option.
D. Incorrect. A weight gain of 8 pounds would likely be insufficient for a client with a pre-pregnancy BMI of 30.5.

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A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

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