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A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?
- A. Encourage the client to spend time in the day room.
- B. Withdraw the client's TV privileges if they do not attend group therapy.
- C. Encourage the client to take frequent rest periods.
- D. Place the client in seclusion when they exhibit signs of anxiety.
Correct Answer: C
Rationale: Encouraging the client to take frequent rest periods is an appropriate intervention for managing mania in a client with bipolar disorder. During a manic episode, individuals often have increased energy levels, decreased need for sleep, and may engage in high-risk behaviors. Encouraging regular rest periods can help reduce stimulation and promote relaxation, which may assist in stabilizing mood. Choices A and B are not as effective in managing manic symptoms, as they do not directly address the client's need for rest and relaxation. Choice D is inappropriate because placing the client in seclusion can increase feelings of anxiety and agitation, worsening the manic episode.
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A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?
- A. Monitor the client's IV site for thrombophlebitis
- B. Administer flumazenil to the client
- C. Evaluate the client for further suicidal behavior
- D. Initiate seizure precautions for the client
Correct Answer: B
Rationale: In cases of benzodiazepine overdose, such as diazepam ingestion, flumazenil is the antidote. Therefore, the priority action for the nurse is to administer flumazenil to the client. Monitoring the IV site for thrombophlebitis (Choice A) is important but not the immediate priority. Evaluating the client for further suicidal behavior (Choice C) is important but not the next immediate action. Initiating seizure precautions (Choice D) is not the priority as the client's airway has already been secured.
A nurse is reviewing the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse expect to include?
- A. Encourage group activities to promote socialization.
- B. Encourage the client to take frequent naps throughout the day.
- C. Provide the client with frequent high-calorie snacks.
- D. Promote physical activity during mealtimes to stimulate appetite.
Correct Answer: C
Rationale: Providing high-calorie snacks is essential when caring for a client in the manic phase of bipolar disorder because they often have increased energy expenditure and may not eat adequately due to their heightened activity levels. Encouraging group activities (Choice A) may overwhelm the client further during this phase. Encouraging frequent naps (Choice B) contradicts the need to manage increased energy levels. Promoting physical activity during mealtimes (Choice D) may not be appropriate as it can distract the client from eating, which is crucial in meeting their nutritional needs.
A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?
- A. Administer magnesium sulfate.
- B. Place the client in the left lateral position.
- C. Monitor intake and output.
- D. Provide a low-sodium diet.
Correct Answer: C
Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.
A client has a new prescription for furosemide. Which of the following instructions should the nurse include?
- A. Take this medication with a full glass of water in the morning.
- B. Monitor your blood pressure daily while taking this medication.
- C. Take this medication at bedtime to prevent nocturia.
- D. Avoid taking this medication with food.
Correct Answer: A
Rationale: The correct answer is to instruct the client to take furosemide with a full glass of water in the morning. Furosemide is a diuretic that can cause increased urination, so it is best taken earlier in the day to avoid disrupting sleep with nocturia. Choice B is not the priority instruction for furosemide. Choice C is incorrect as taking furosemide at bedtime can lead to nocturia, which is undesirable. Choice D is incorrect because furosemide can be taken with or without food.
A nurse is preparing to administer an IV medication to a client who reports a latex allergy. Which of the following actions should the nurse take?
- A. Place the client in a supine position.
- B. Use non-latex gloves when administering the medication.
- C. Use latex-free syringes when administering the medication.
- D. Administer the medication through a latex-free IV port.
Correct Answer: D
Rationale: The correct action the nurse should take when preparing to administer an IV medication to a client with a latex allergy is to administer the medication through a latex-free IV port. This measure helps prevent allergic reactions in clients with a known latex allergy. Placing the client in a supine position (Choice A) is not directly related to preventing a latex allergy reaction. Using non-latex gloves (Choice B) is important for protecting the nurse or caregiver from latex exposure but does not prevent the client's allergic reaction. While using latex-free syringes (Choice C) is a good practice, ensuring the IV port is latex-free is more crucial in preventing an allergic response in the client.