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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
B. Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
C. Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
D. Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
Correct Answer is D
Explanation
A. Incorrect. Applying an ice pack to the affected extremity is not recommended for a client with deep vein thrombosis, as it could potentially exacerbate the condition by promoting vasoconstriction.
B. Correct. Administering aspirin for pain relief is an appropriate action for a client with deep vein thrombosis. Aspirin has anti-inflammatory and analgesic properties and can help manage pain associated with thrombosis.
C. Incorrect. Massaging the affected extremity is contraindicated for a client with deep vein thrombosis, as it can dislodge the clot and pose a risk of embolization.
D. Incorrect. Initiating bed rest is not recommended for a client with deep vein thrombosis.
Encouraging early ambulation and mobilization can help prevent complications such as thrombus extension and pulmonary embolism.
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