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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. Incorrect. Cimetidine is not known to interact significantly with enoxaparin.
B. Incorrect. Docusate is a stool softener and does not typically interact with enoxaparin.
C. Incorrect. While calcium supplements may interact with certain medications, there's no significant interaction between calcium supplements and enoxaparin.
D. Correct. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID. and can increase the risk of bleeding when taken with anticoagulants like enoxaparin. Therefore, it's considered unsafe to use both together.
Correct Answer is C
Explanation
A. Incorrect. In the event of an outdoor chemical disaster, individuals should stay indoors and take shelter rather than exiting the home.
B. Incorrect. Opening the dampers of fireplaces could allow outdoor contaminants to enter the home.
C. Correct. Covering heat registers with plastic and tape can help prevent outdoor chemicals from entering the home through the ventilation system.
D. Incorrect. Turning on ceiling fans and air conditioners could potentially bring outdoor contaminants indoors through the ventilation system.
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