The nurse continues to care for the client.
For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client
Provide the client with high-calorie fluids every hour.
Encourage the client to avoid napping during the day.
Minimize environmental stimuli for the client.
Weigh the client each day.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Rationale:
- Provide the client with high-calorie fluids every hour: The client has poor self-care, has not eaten for an extended period, and exhibits hyperactivity due to mania. Frequent high-calorie fluids help maintain hydration and meet increased metabolic demands. Regular intake supports nutrition and prevents further weight loss.
- Encourage the client to avoid napping during the day: Avoiding daytime napping can help regulate sleep-wake cycles and promote restorative sleep at night. Clients experiencing mania often have decreased need for sleep, so reinforcing nighttime sleep routines supports stabilization of circadian rhythms.
- Minimize environmental stimuli for the client: Clients experiencing a manic episode are easily overstimulated, which can worsen their agitation, anxiety, and psychosis. A calm, quiet environment with reduced distractions is essential for de-escalation and promoting rest.
- Weigh the client each day: Daily weight monitoring helps assess nutritional status and detect fluid imbalance, which is important given the client’s poor self-care, hyperactivity, and potential for dehydration or rapid weight loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.
B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.
C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.
D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.
Correct Answer is B
Explanation
A. Splitting behavior: Splitting, or viewing people as all good or all bad, is characteristic of borderline personality disorder rather than histrionic personality disorder. It reflects difficulty integrating positive and negative aspects of self and others.
B. Emotional lability: Clients with histrionic personality disorder often display rapidly shifting emotions, exaggerated expression of feelings, and attention-seeking behaviors. Emotional lability is a hallmark feature, making this an expected manifestation.
C. Self-centered behavior: While clients with histrionic personality disorder may seek attention, overt self-centeredness and grandiosity are more characteristic of narcissistic personality disorder rather than histrionic traits.
D. Suspicious of others: Suspiciousness and distrust are typical of paranoid personality disorder. Clients with histrionic personality disorder are generally sociable and seek approval rather than displaying pervasive mistrust.
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