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A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.
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Give Dobutamine 5.5 mcg/kg/min. The drug is available as 750 mg in 500 ml of fluid. The client weighs 220 pounds. Calculate mcg/min, mcg/hr, and ml/hr. (Include the unit of measure for each answer).
Correct Answer: 22
Rationale: To calculate mcg/min: 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. To convert mcg/hr: 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. To find ml/hr: 750 mg / 500 ml = 1.5 mg/ml. 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. 66,000 mcg/hr / 1,000 = 66 mg/hr. 66 mg/hr / 1.5 mg/ml = 44 ml/hr. Therefore, the correct answer is 22 mcg/min, 66,000 mcg/hr, and 44 ml/hr. Other choices are
A nurse is planning care for a client who has hyperthyroidism and is receiving radioactive iodine (radioiodine). Which of the following statements by the nurse regarding special precautions is appropriate?
- A. You will need to use a bathroom separate from other household members.
- B. You will need to remain at the hospital for the entire time the radioiodine is radioactive.
- C. A low fiber diet will be necessary.
- D. Additional Immunizations will be needed for full protection.
Correct Answer: A
Rationale: Rationale: Choice A is correct because radioiodine is excreted through bodily fluids including urine. Using a separate bathroom prevents exposure to others. Choice B is incorrect as hospitalization isn't always required. Choice C is irrelevant to radioiodine therapy. Choice D is incorrect as immunizations are not directly related to radioiodine precautions.
Claudette, the nurse, is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication
- A. I feel angry when you leave me.
- B. I wish you would not make me angry.
- C. It makes me angry when you interrupt me.
- D. You'd better listen to me.
Correct Answer: D
Rationale: The correct answer is D because it is an example of aggressive communication. The statement "You'd better listen to me" is forceful, directive, and implies a threat if the listener does not comply. This type of communication lacks respect for the other person's feelings and boundaries. In contrast, choices A, B, and C express personal feelings and thoughts without being demanding or confrontational. Choice A uses "I feel" to express emotions, choice B expresses a wish without placing blame, and choice C explains a reaction to a specific behavior without being forceful. Therefore, D stands out as the only example of aggressive communication in the given options.
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
- A. A client attempts to climb out of bed and repeatedly states she must get home.
- B. A client refuses to get out of bed and has no motivation to attend to daily hygiene.
- C. A client wants to know the current time while there is a clock on the wall.
- D. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).
Correct Answer: A
Rationale: The correct answer is A. Delirium is characterized by sudden onset confusion and disorientation. In this case, the client attempting to climb out of bed and repeatedly stating she must get home indicates altered mental status and confusion, which are common in delirium. The other choices do not align with typical manifestations of delirium. Choice B suggests lack of motivation, choice C is a normal behavior to check the time, and choice D is a reasonable request based on personal preference rather than a sign of delirium.
A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches,the client states I am at the end of my rope. I don’t think I can take any more bad news. Which of the following responses should the nurse make?
- A. An anti-anxiety pill works best for situations like this.
- B. Most clients with anxiety issues benefit from lying down.
- C. Providers usually recommend relaxation exercises for clients who are as upset as you are.
- D. Come with me to an area where we can talk without interruption.
Correct Answer: D
Rationale: Inviting the client to a quiet area offers support and encourages expression of concerns.