A nurse is caring for a client diagnosed with bipolar disorder in an acute manic state. The client is running around the unit asking people to dance with her. After ensuring safety, which of the following interventions should the nurse take?

Turn on a dance video so the client can burn off excess energy.

Take the client to a calm environment and offer snacks.

Offer the client a low-calorie snack in return for stopping the behavior.

Observe the client closely for the development of aggressive behavior.

Answer and Explanation

The Correct Answer is B

Choice A: Turn on a dance video so the client can burn off excess energy.
This intervention might help the client to channel their energy in a safe and controlled manner. However, it might also reinforce the manic behavior, which could be counterproductive in the long term.

Choice B: Take the client to a calm environment and offer snacks.
This intervention could help to distract the client from their manic behavior and provide them with a calming and grounding experience. Offering snacks could also help to stabilize their energy levels.

Choice C: Offer the client a low-calorie snack in return for stopping the behavior.
This intervention could be seen as a form of behavioral reinforcement. However, it might not be effective if the client is not motivated by food or if they perceive it as a form of manipulation.

Choice D: Observe the client closely for the development of aggressive behavior.
This intervention is crucial for ensuring the safety of the client and others in the unit. If the client's behavior escalates to aggression, the nurse would need to take immediate steps to de-escalate the situation and protect everyone involved.

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Correct Answer is B

Explanation

Choice A reason:
Eating foods high in tyramine is not a risk factor for lithium toxicity. Tyramine is associated with dietary restrictions in patients taking monoamine oxidase inhibitors, not lithium.

Choice B reason:
Engaging in activities that cause excessive sweating, such as running 4 miles outdoors every afternoon, can lead to dehydration. Dehydration is a significant risk factor for lithium toxicity because it can increase lithium levels in the blood, potentially leading to toxicity.

Choice C reason:
Drinking 2 liters of liquids daily is generally recommended for hydration and is not a risk factor for lithium toxicity. Adequate hydration can help prevent lithium toxicity by ensuring that lithium is properly excreted through the kidneys.

Choice D reason:
Eating 2 to 3 grams of sodium-containing foods daily is within normal dietary intake ranges and is not a risk factor for lithium toxicity. Maintaining a consistent sodium intake is important when taking lithium, as low sodium levels can lead to increased lithium retention and potential toxicity.

A. The client's at-home dose should be decreased. B. The client may need an increased dose to control symptoms. C. Xanax (alprazolam) does not cause dependency. D. Ativan (Lorazepam) can be added to the client's medications.

Correct Answer is A

Explanation

Choice A reason:
Decreasing the dose of Xanax (alprazolam) is often necessary when a client shows signs of dependency or when there are concerns about potential side effects, such as uncontrolled hypertension. Xanax is a fast-acting benzodiazepine, which can be highly addictive, especially when taken in doses of 4 mg/day for longer than 12 weeks. It is essential to monitor the client's blood pressure and adjust the medication accordingly to avoid exacerbating hypertension.

Choice B reason:
Increasing the dose may temporarily control symptoms of anxiety, but it also increases the risk of dependency and other side effects. Given the client's uncontrolled hypertension, increasing the dose could lead to further complications.

Choice C reason:
This statement is incorrect. Xanax does cause dependency, and it is one of the most addictive benzodiazepine medications on the market today. Dependency can develop quickly, even in users who follow a prescribed dosing schedule.

Choice D reason:
While Ativan (Lorazepam) is also used to treat anxiety, adding it to the client's medication regimen without careful consideration could increase the risk of dependency and adverse effects. Both Xanax and Ativan are benzodiazepines, and their combined use should be monitored closely by a healthcare professional.

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A nurse is caring for a client diagnosed with bipolar disorder in an acute manic state. The client is running around the unit asking people to dance with her. After ensuring safety, which of the following interventions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

Correct Answer is B

Explanation

A nurse is caring for a client who has been taking Xanax (alprazolam) for anxiety. The nurse anticipates which of the following?

Correct Answer is A

Explanation

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

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A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

The nurse is caring for a client who has a history of alcohol use disorder and is experiencing withdrawal symptoms. Which of the following should be the priority action by the nurse?

A nurse is caring for a client diagnosed with bipolar disorder in an acute manic state. The client is running around the unit asking people to dance with her. After ensuring safety, which of the following interventions should the nurse take?

A nurse is caring for a client with a blood alcohol level of 36%. Which of the following should be included in the priority risk assessment for a client with acute alcohol intoxication? (Select all that apply)

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?