The nurse is caring for a client experiencing mania who is pacing, cannot sit, with pressured speech. Which meal will the nurse provide to best meet the nutritional needs of this client?

Fried chicken, mashed potatoes, milk

Peanut butter sandwich, chips, cola

Turkey sandwich, cheese slices, milk

Spaghetti, garlic bread, salad, tea

Answer and Explanation

The Correct Answer is C

Choice A reason: Fried chicken and mashed potatoes are high in fat and carbohydrates, which may provide energy but lack balanced nutrition. Milk offers protein, but the meal’s high caloric density may not suit the client’s hyperactive state, requiring lighter, nutrient-dense options.

Choice B reason: A peanut butter sandwich, chips, and cola are high in fat and sugar, providing quick energy but lacking balanced nutrients. Cola’s caffeine may exacerbate mania, increasing agitation, making this meal less suitable for a manic client’s nutritional needs.

Choice C reason: A turkey sandwich, cheese slices, and milk provide balanced protein, carbohydrates, and calcium, supporting energy needs during mania’s hyperactive state. Milk avoids caffeine, which could worsen agitation, making this meal ideal for nutritional balance and calming effects.

Choice D reason: Spaghetti, garlic bread, and salad are nutritious but carbohydrate-heavy, potentially causing energy spikes and crashes in manic clients. Tea may contain caffeine, increasing agitation, making this meal less optimal than a balanced, low-stimulant option.

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Correct Answer is C

Explanation

Choice A reason: Drawing blood for lab studies, such as BNP or electrolytes, is important in heart failure to assess severity and guide treatment. However, 2+ pitting edema and left ventricular enlargement suggest acute pulmonary congestion, making respiratory assessment the priority to detect life-threatening complications like pulmonary edema.

Choice B reason: Weighing the client monitors fluid status in heart failure, as weight gain indicates fluid retention. While important, it is secondary to assessing respiratory status, as edema and ventricular enlargement suggest possible pulmonary edema, which poses an immediate threat to oxygenation.

Choice C reason: Left ventricular enlargement and 2+ pitting edema indicate left-sided heart failure, which can lead to pulmonary edema, causing dyspnea and hypoxia. Assessing respiratory status first ensures detection of crackles or respiratory distress, enabling prompt intervention to prevent respiratory failure or worsening heart failure.

Choice D reason: Inserting a Foley catheter monitors urine output in heart failure but is not the first action. Respiratory distress from pulmonary edema, suggested by edema and ventricular enlargement, is a more immediate concern, requiring assessment of breathing to ensure adequate oxygenation and safety.

A. Administer furosemide (Lasix) 80 mg IV as ordered B. Administer a thrombolytic medication C. Prepare for transcutaneous pacing D. Prepare for synchronized cardioversion

Correct Answer is C

Explanation

Choice A reason: Furosemide is a diuretic used for fluid overload in heart failure, not for second-degree AV block Type II, which causes bradycardia and hypotension. Administering it could worsen hypotension by reducing preload, making it inappropriate for this client’s acute conduction issue.

Choice B reason: Thrombolytic medications are used for acute myocardial infarction or stroke to dissolve clots. Second-degree AV block Type II is a conduction disorder, not a thrombotic event, so thrombolytics are irrelevant and could cause harmful bleeding in this scenario.

Choice C reason: Second-degree AV block Type II causes intermittent failure of atrial impulses to conduct, leading to bradycardia and hypotension. Transcutaneous pacing restores heart rate and cardiac output, stabilizing the client’s hemodynamics, making it the most appropriate intervention for this life-threatening rhythm disturbance.

Choice D reason: Synchronized cardioversion is used for tachyarrhythmias like atrial fibrillation or ventricular tachycardia. Second-degree AV block Type II is a bradyarrhythmia, so cardioversion is inappropriate. Pacing is needed to increase heart rate and address the client’s symptoms effectively.

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The nurse is caring for a client experiencing mania who is pacing, cannot sit, with pressured speech. Which meal will the nurse provide to best meet the nutritional needs of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a new client to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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