A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

Provide a flexible activity schedule.

Provide high-calorie nutritional supplements.

Allow the client to eat meals alone in her room.

Allow the client to choose her clothes independently.

Answer and Explanation

The Correct Answer is B

A. This is not an appropriate action for a client experiencing acute mania. A flexible activity schedule may exacerbate symptoms by allowing too much freedom, leading to overstimulation and a lack of focus. Structured activities with clear boundaries are more effective for managing manic behaviors.

B. Providing high-calorie nutritional supplements is essential for clients in acute mania because they often exhibit hyperactivity and may neglect to eat or drink adequately. These supplements help maintain nutritional balance and prevent weight loss or dehydration during this period of heightened energy and poor self-care.

C. Allowing the client to eat meals alone in her room is not appropriate. Clients with acute mania benefit from supervised, structured environments to ensure they are eating and engaging in necessary self-care. Isolation may also increase feelings of disorganization or exacerbate symptoms.

D. Allowing the client to choose her clothes independently is not recommended during acute mania, as poor judgment and impulsivity may lead to inappropriate or excessive clothing choices. Providing simple, preselected clothing options helps reduce decision-making stress and ensures appropriate attire.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and

the client's condition, not solely on the presence of a radiation implant.

B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.

C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.

D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate

protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.

A. Head circumference 1 cm greater than chest B. Positive Babinski reflex on bilateral feet C. Passage of meconium stool D. Pinna below the outer canthus of the eye

Correct Answer is D

Explanation

A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.

B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.

C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.

D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.

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A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?