A nurse is admitting a patient exhibiting manic behavior.
The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?

Encourage self-care.

Assist the patient in identifying coping behaviors.

Prevent self-directed violence.

Identify support systems.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.

Choice B rationale

Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.

Choice C rationale

Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.

Choice D rationale

Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

When caring for a patient who practices Islam, the nurse should request a meal tray without pork. Dietary laws in Islam, known as halal, prohibit the consumption of pork.

A. Increasing IV fluid rate B. Encouraging the client to sit up without assistance C. Administering antiemetic medication D. Monitoring respiratory rate closely E. Providing reassurance and calming interventions F. Checking electrolyte levels regularly

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Action	Essential	Nonessential	Contraindicated
Increasing IV fluid rate		The current rate is prescribed by the provider; increasing it without further assessment could lead to complications.
Encouraging the client to sit up without assistance		The client feels faint upon sitting up and is unsteady, so this could be dangerous.
Administering antiemetic medication	Helpful but not immediately critical.
Monitoring respiratory rate closely	Crucial due to client's rapid breathing and anxiety.
Providing reassurance and calming interventions	Important due to client's anxiety and discomfort.
Checking electrolyte levels regularly	Essential for ongoing monitoring given the client's symptoms.

Essential

Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.
Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.
Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.
Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is admitting a patient exhibiting manic behavior.The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a patient who practices Islam. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Essential

Nonessential

Contraindicated

A nurse is planning a meal for a patient who has diverticulitis. Which menu selection should the nurse include in the plan?

The nurse is preparing a medication for a patient and observes the date of expiration on the vial occurred 2 months ago.Which of the following actions should the nurse take?

A nurse is assessing a patient who has schizophrenia and is taking aripiprazole. The nurse should notify the provider of which of the following findings?

2100 hrs - Critical Incident Exhibits A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?

A patient is starting celecoxib to treat osteoarthritis.What adverse effects should the nurse instruct the patient to monitor and report?

A nurse manager is providing staff education about working with patients who have a history of anger and aggression.Which of the following information should the nurse include in the teaching?

A nurse is caring for a patient suspected of having compromised blood flow to a limb. What factors contribute to poor circulation to the limb?

A nurse is admitting a patient exhibiting manic behavior.
The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?