A nurse is caring for a client in the emergency department (ED). The client comes to the ED via ambulance. The client has a history of bipolar disorder and is experiencing acute mania.
Select the 3 prescriptions that the nurse should anticipate for this client.
Administer 0.9% sodium chloride IV.
Administer IV flumazenil.
Prepare the client for intubation.
Begin chest compressions
Administer IV naloxone.
Administer activated charcoal.
Prepare the client for electroconvulsive therapy (ECT).
Correct Answer : A,E,G
The correct answer/s is Choice/s A, E, and G.
Choice A rationale: Administering 0.9% sodium chloride IV is a common practice in emergency departments to ensure the patient is well-hydrated. This is particularly important for patients experiencing acute mania, as they may have neglected their physical health, including hydration, during their manic episode.
Choice B rationale: Flumazenil is an antagonist for benzodiazepines and is typically used to reverse the sedative effects of benzodiazepines. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice C rationale: Preparing the client for intubation is usually reserved for situations where the patient is unable to maintain their own airway or adequate ventilation. This is not typically necessary in cases of acute mania unless there are other complicating factors.
Choice D rationale: Beginning chest compressions is a response to cardiac arrest. There is no indication in the that the patient is experiencing cardiac arrest, so this would not be a typical anticipation for a patient experiencing acute mania.
Choice E rationale: Administering IV naloxone is done in cases of suspected opioid overdose. While it’s not directly related to treating acute mania, it’s possible that the patient could have comorbid substance use issues, given the high rate of comorbidity between bipolar disorder and substance use disorders.
Choice F rationale: Administering activated charcoal is done in cases of certain types of poisoning or drug overdose. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice G rationale: Preparing the client for electroconvulsive therapy (ECT) could be an appropriate anticipation for a patient experiencing acute mania. ECT is considered a highly effective treatment for severe mania, particularly when other treatments have failed or when rapid stabilization is required.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This response indicates anger, not denial. The client is expressing anger towards the doctor and their perceived lack of competence. While anger can be a component of the grief process, it does not specifically align with the denial phase, which is characterized by a refusal to accept the reality of a situation.
Choice B rationale:
This response indicates fatigue or depression, not denial. The client is acknowledging their physical and emotional state but is not expressing disbelief or refusal to accept their diagnosis.
Choice C rationale:
This response clearly demonstrates denial. The client is minimizing the severity of their diagnosis and attributing the doctor's statements to an ulterior motive. This is a classic example of denial, as it involves a distortion of reality to avoid facing a painful truth.
Choice D rationale:
This response indicates acceptance, not denial. The client is acknowledging the reality of their situation and expressing gratitude for the care they have received.
Correct Answer is C
Explanation
Choice A rationale:
While assigning a client to a private room might seem like a way to protect their privacy and offer a calm environment, it could also create isolation and reduce opportunities for observation by staff. This could increase the risk of a subsequent suicide attempt without timely intervention.
It's essential to balance privacy with safety needs, and a private room might not always be the most appropriate choice for a client who has recently attempted suicide.
Choice B rationale:
Placing metal utensils on the client's meal tray could introduce potential weapons that could be used for self-harm. It's crucial to remove any objects that could be used for suicide attempts, including utensils, sharp objects, belts, cords, or medications.
Providing safe alternatives, such as plastic utensils, is essential to reduce the risk of harm.
Choice C rationale:
Inspecting the client's personal belongings is a critical safety measure to ensure they don't have access to items that could be used for self-harm. This includes checking for sharp objects, medications, ropes, belts, or other potential hazards.
Removing any such items is essential to create a safe environment and reduce the risk of further suicide attempts.
Choice D rationale:
Tucking bedcovers over the client's hands and arms might restrict their movement, but it doesn't address the underlying risk of suicide. It's not an effective method of preventing self-harm, and it could even cause discomfort or agitation to the client.
More direct and comprehensive safety measures, such as close observation and removal of potential hazards, are necessary.
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