The nurse continues to care for the client.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.
Correct Answer is B
Explanation
A. "Administer this medication as needed for symptom control." Fluticasone is an inhaled corticosteroid used for long-term control, not for acute symptom relief. It should be administered on a regular schedule, not as needed.
B. "Rinse mouth and gargle with water after each use." Rinsing the mouth helps prevent oral thrush (candidiasis), a common side effect of inhaled corticosteroids like fluticasone. It reduces residual medication in the mouth and supports good oral hygiene.
C. “Administer this medication before any other inhaled medications.” Fluticasone should be given after bronchodilators, such as albuterol, if both are prescribed. Administering a bronchodilator first opens the airways and allows the corticosteroid to work more effectively.
D. "Growth may be accelerated while using this medication?” Inhaled corticosteroids may cause slowed growth in some children with long-term use, though the effect is generally small and outweighed by the benefits of asthma control.
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