Nokea
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
- A. Confront the client with the fact that she will have to eat more from her tray to sustain her
- B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition
- C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times
- D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.
You may also like to solve these questions
The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?
- A. "You should see the doctor every six months."
- B. "Sunbathing should be done between the hours of noon and 3 p.m."
- C. "If you have a mole, it should be removed and biopsied."
- D. "You should wear sunscreen when going outside."
Correct Answer: D
Rationale: Wearing sunscreen protects against UV radiation, a key skin cancer risk factor. Regular checkups (A) are less specific, sunbathing at peak hours (B) increases risk, and routine mole removal (C) is excessive.
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis, suggesting inadequate ventilation and the need for mechanical ventilation. PCO2 58 (A) and HCO3 30 (D) are elevated but less critical, and SaO2 90 (B) is low but not definitive.
A client with a history of heart failure is receiving Carvedilol (Coreg). The nurse should monitor the client for:
- A. Hypotension
- B. Hyperglycemia
- C. Tachycardia
- D. Weight gain
Correct Answer: A
Rationale: Carvedilol, a beta-blocker, can cause hypotension due to vasodilation and reduced heart rate. Hyperglycemia, tachycardia, and weight gain are not primary concerns.
An appropriate nursing intervention for the client with borderline personality disorder is:
- A. Observing the client for signs of depression or suicidal thinking
- B. Allowing the client to lead unit group sessions
- C. Restricting the client's activity to the assigned unit of care throughout hospitalization
- D. Allowing the client to select a primary caregiver
Correct Answer: A
Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Cullen's sign
- B. Rebound tenderness
- C. Murphy's sign
- D. Turner's sign
Correct Answer: C
Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.