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 B
Explanation
A. Weight loss is a potential side effect of methylphenidate, but it is not a direct indicator of medication effectiveness.
B. Correct. Improved ability to complete tasks like homework can be a positive indication of the medication's effectiveness in managing ADHD symptoms.
C. Increased caloric intake might not be directly related to the medication's effectiveness.
D. "A better grasp of reality" is a vague statement and not a specific indicator of ADHD medication effectiveness.
Correct Answer is A
Explanation
A. Correct. MRSA is spread through direct contact with infected skin or surfaces. Wearing gloves when providing care to a client with MRSA helps prevent the spread of the bacteria.
B. Incorrect. The use of HEPA filters and negative air pressure is typically reserved for airborne infections such as tuberculosis. MRSA is primarily spread through direct contact.
C. Incorrect. Negative air pressure is not typically necessary for preventing the spread of MRSA, which is primarily spread through contact.
D. Incorrect. Wearing a mask when out of the room is not a standard precaution for MRSA, which is not primarily transmitted through the airborne route.
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