The nurse continues to care for the client.

Exhibits

A nurse on the inpatient mental health unit is planning 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 hr.

Minimize environmental stimuli for the client.

Weigh the client each day.

Encourage the client to avoid napping during the day.

Answer and Explanation

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

Provide the client with high-calorie fluids every hr: Clients in manic states often experience poor nutritional intake due to hyperactivity and distractibility. Frequent, easy-to-consume high-calorie fluids help support caloric and hydration needs without requiring the client to sit for meals, making this an appropriate intervention.
Minimize environmental stimuli for the client: Clients experiencing mania are often overstimulated and agitated due to their heightened sensitivity and rapid thought processes. A low-stimulation environment helps reduce agitation, prevent escalation, and promote safety.
Weigh the client each day: While weight monitoring may be important in some psychiatric or medical conditions, daily weights are not a priority in the acute management of mania, particularly when the client is hyperactive, distracted, and unable to participate reliably. This could also increase agitation or preoccupation in some clients.
Encourage the client to avoid napping during the day: Manic clients often suffer from significantly reduced sleep, which contributes to worsening symptoms. Encouraging rest and short naps would be more therapeutic than promoting wakefulness, so avoiding naps is contraindicated in this scenario.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.

A. Educating clients about contraindications to specific immunizations B. Providing clients with information about the benefits of exercise C. Using an electronic messaging system to remind clients when to take medications D. Helping clients understand health screenings covered by their insurance plans

Correct Answer is C

Explanation

A. Educating clients about contraindications to specific immunizations. This is an example of primary prevention, which aims to prevent disease before it occurs by promoting safe practices and avoiding harmful exposures.
B. Providing clients with information about the benefits of exercise. This also falls under primary prevention, as it promotes a healthy lifestyle to prevent the onset of disease or complications.
C. Using an electronic messaging system to remind clients when to take medications. This is an example of tertiary prevention, which focuses on managing chronic conditions (like HIV) and preventing complications or progression of the disease through adherence support.
D. Helping clients understand health screenings covered by their insurance plans. This is considered secondary prevention, which involves early detection and prompt intervention to catch diseases in the early stages through screenings.

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The nurse continues to care for the client. Exhibits A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?

Correct Answer is C

Explanation

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

A nurse is caring for a client who is receiving IV fluid therapy. For which of the following findings should the nurse monitor as an adverse effect of the IV fluid therapy?

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

A nurse is caring for a client who is receiving chemotherapy. The client tells the nurse they do not want to receive further treatment. Which of the following responses should the nurse make?

A nurse is teaching a class about infection control to a group of nurses. The nurse should identify which of the following diseases as requiring the implementation of droplet precautions?

A nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of combination oral contraceptives?

A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include?

The nurse continues to care for the client.

Exhibits

A nurse on the inpatient mental health unit is planning care for the client.

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.