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 A
Explanation
A. Correct. Assessing whether the client has a plan for self-harm is a priority in evaluating the immediate risk of suicide. If a plan is present, further assessment and intervention are needed.
B. Incorrect. While having support is important, knowing whether the client has a plan for self-harm takes precedence.
C. Incorrect. While a family history of suicide is a risk factor, it is not as immediate a concern as determining whether the client has a current plan.
D. Incorrect. Assessing the sources of stress is important, but the immediate risk of self-harm takes priority.
Correct Answer is B
Explanation
A. "If you are allergic to gluten you should not receive this vaccine."Gluten allergy is not a contraindication for the MMR vaccine. The vaccine does not contain gluten, and an allergy to gluten would not prevent someone from safely receiving the vaccine. However, individuals with severe allergies to neomycin or gelatin (which are components of the vaccine) should not receive it.
B. "Avoid pregnancy for at least 28 days after receiving the vaccine."The MMR vaccine contains live attenuated viruses, and there is a theoretical risk to the fetus if a woman becomes pregnant shortly after vaccination. Therefore, it is recommended that women avoid becoming pregnant for at least 28 days after receiving the MMR vaccine to reduce any potential risks.
C. "Avoid breastfeeding for 3 days after receiving the vaccine."The MMR vaccine is safe for breastfeeding mothers and does not require any interruption in breastfeeding. The vaccine viruses are not transmitted through breast milk in a way that would harm the infant.
D. "Your partner should also receive the MMR vaccine."While it is important for all individuals to be up-to-date on their vaccinations, the partner's vaccination status is unrelated to the postpartum administration of the MMR vaccine to the client. This instruction does not address a specific concern related to the postpartum period or the MMR vaccine's administration at this time.
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