Nokea
A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?
- A. Encourage the client to take frequent rest periods.
- B. Withdraw TV privileges if the client does not attend group therapy.
- C. Place the client in seclusion during periods of anxiety.
- D. Encourage the client to spend time in the day room.
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.
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A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head uncovered.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct Answer: C
Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.
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 chronic kidney disease and a serum potassium level of 6.5 mEq/L. Which of the following actions should the nurse take?
- A. Administer sodium bicarbonate
- B. Administer sodium polystyrene sulfonate
- C. Administer calcium gluconate
- D. Administer calcium carbonate
Correct Answer: B
Rationale: The correct action for the nurse to take is to administer sodium polystyrene sulfonate. This medication promotes potassium excretion and helps lower serum potassium levels in clients with hyperkalemia, which is indicated by a high potassium level. Sodium bicarbonate (choice A) is not used to treat hyperkalemia. Calcium gluconate (choice C) and calcium carbonate (choice D) are used to manage hyperkalemia by stabilizing cell membranes but are not the initial treatment choice for lowering potassium levels.
A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?
- A. Blood urea nitrogen (BUN) 25 mg/dL
- B. Serum creatinine 1.5 mg/dL
- C. Serum glucose 110 mg/dL
- D. White blood cell (WBC) count 5,000/mm3
Correct Answer: A
Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?
- A. Store unopened vials of insulin in the refrigerator, not the freezer.
- B. Rotate injection sites within the same region to prevent tissue damage.
- C. Administer insulin at a 90-degree angle for subcutaneous injections.
- D. Avoid massaging the injection site after administering insulin.
Correct Answer: B
Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.