The nurse is reviewing the medical records of the client who is exhibiting mania. Which of the following actions should the nurse take? Select all that apply.
Vital Signs 0800:
Heart rate 110/min Respiratory rate 20/min
Blood pressure 132/80 mm Hg Temperature 37.2° C (99° F)
1100:
Heart rate 120/min
Respiratory rate 24/min
Blood pressure 149/90 mm Hg Temperature 37.2° C (98.9° F)
Encourage the client to avoid caffeine.
Report lithium level to the provider.
Provide step-by-step reminders regarding hygiene.
Involve the client in group activities.
Encourage the client to eat finger foods frequently.
Redirect aggressive behaviors
Monitor the blood pressure and heart rate every 4 hr.
Weigh the client daily.
Correct Answer : A,B,C,E,F,G,H
A. Caffeine can exacerbate symptoms of mania by increasing restlessness and irritability. Avoiding caffeine can help in managing these symptoms.
B. Lithium is a common medication used to manage manic episodes in bipolar disorder. Monitoring lithium levels is crucial to ensure the client's safety and therapeutic effectiveness.
C. Clients experiencing mania may have difficulty focusing and completing tasks, including personal hygiene. Step-by-step reminders can help the client maintain proper hygiene.
D. While social interaction can be beneficial, clients in a manic state may become overstimulated or disruptive in group settings. Individual activities are often more appropriate until the mania is better controlled.
E. Clients in a manic state may be too restless to sit down for meals. Offering finger foods allows them to eat while on the go, helping to maintain adequate nutrition.
F. Clients with mania may exhibit aggressive behaviors. Redirecting these behaviors to safer or more appropriate outlets is important for the safety of the client and others.
G. The client's vital signs indicate an increase in heart rate and blood pressure, which are important to monitor closely as they can be affected by the heightened physical activity and agitation associated with mania.
H. Lithium can cause fluid retention and weight gain. Daily weight monitoring helps detect sudden increases that may indicate fluid imbalance or early signs of lithium toxicity. It also assists in managing and adjusting treatment as needed to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Route.
Choice A rationale:
The time of administration is typically specified in the prescription and does not usually require clarification unless there are specific concerns about timing with other medications or meals.
Choice B rationale:
The medication, erythromycin, is clearly specified in the prescription. There is no ambiguity about which medication is being prescribed.
Choice C rationale:
The dosage of 500 mg is clearly stated and is a standard dose for erythromycin. There is no need to clarify this unless there are specific patient concerns or conditions that might affect dosing.
Choice D rationale:
The route of administration (e.g., oral, intravenous) is crucial information that must be clarified if not specified.Erythromycin can be administered in multiple ways, and the effectiveness and side effects can vary depending on the route
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
Incorrect Options
- Osteoporosis: This condition is primarily characterized by bone density loss and an increased risk of fractures. It would not be indicated by bilateral wrist and shoulder stiffness. Instead, osteoporosis symptoms include bone density loss and potentially fractures.
- Hypertension: Hypertension involves consistently high blood pressure. Bilateral wrist and shoulder stiffness are not typical symptoms of hypertension. The primary indicator for hypertension is elevated blood pressure.
- Diabetes Mellitus: This metabolic disorder is characterized by high blood glucose levels. Symptoms related to diabetes include elevated blood glucose levels, not joint stiffness.
- Chronic Obstructive Pulmonary Disease (COPD): COPD is a respiratory condition marked by shortness of breath, chronic cough, and other respiratory symptoms. It would not be indicated by joint stiffness but rather by respiratory difficulties such as shortness of breath.
In contrast, rheumatoid arthritis is an autoimmune disease that primarily affects the joints, leading to symptoms such as bilateral wrist and shoulder stiffness. Therefore, the correct answer is "rheumatoid arthritis" and "bilateral wrist and shoulder stiffness," while the incorrect options provided do not align with the symptoms of rheumatoid arthritis.
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