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 D
Explanation
A. Revise the current policy for catheter care. Policy changes should be based on evidence and root cause analysis. Revising the policy prematurely without identifying contributing factors may not address the actual causes of infection.
B. Schedule nursing staff training for infection control procedures. Education and training are important but should be guided by identified gaps. Implementing training without understanding the root cause may result in ineffective interventions.
C. Meet with providers to discuss measures to decrease the infections. While interdisciplinary collaboration is valuable, it should occur after gathering and analyzing relevant data. This ensures targeted, evidence-based recommendations.
D. Identify possible precipitating factors related to the infections. The first step in quality improvement is to investigate and assess contributing factors. This helps guide the most appropriate and effective interventions to reduce infection rates.
Correct Answer is B
Explanation
A. Social worker. While a social worker can assist with emotional or financial concerns, they are not involved in managing oxygen delivery systems or therapy adherence related to medical devices.
B. Respiratory therapist. The respiratory therapist is the most appropriate team member to consult regarding oxygen delivery methods. They can assess the client’s needs, explain alternatives (e.g., nasal cannula instead of a mask), and help promote comfort and compliance with therapy.
C. Assistive personnel. Assistive personnel can support basic care tasks, but they are not trained to adjust or manage oxygen therapy or address client concerns about medical treatments.
D. Occupational therapist. Occupational therapists assist clients in regaining independence with daily activities, not in managing oxygen therapy. This issue is outside their scope of practice.
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