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. Incorrect. While expressing empathy is important, the nurse should also provide practical information and support.
B. Incorrect. Delaying the discussion may leave the client feeling unheard and anxious about their upcoming chemotherapy.
C. Correct. This response acknowledges the client's concerns and provides a proactive solution to address the potential issue of hair loss. Offering information about head covering options demonstrates the nurse's support and willingness to help the client manage the physical and emotional impact of chemotherapy.
D. Incorrect. Dismissing the client's concern may contribute to their anxiety and apprehension about the chemotherapy process. It's important to address all aspects of the client's experience, including potential side effects like hair loss.
Correct Answer is D
Explanation
A. Incorrect. Assisting the client with relaxation techniques can be helpful in managing bladder training, but determining the client's voiding pattern is the first step in designing an effective program.
B. Incorrect. Discouraging the intake of carbonated beverages might be part of the bladder training plan, but the first step is to assess the client's current voiding pattern.
C. Incorrect. Offering toileting opportunities every 1 to 2 hours is part of the bladder training program, but determining the client's voiding pattern is the initial action.
D. Correct. The nurse should first determine the client's pattern for voiding, including the frequency of voiding and any patterns of urgency or incontinence. This information is essential to tailor the bladder training program to the client's individual needs.
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