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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 assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer?
- A. Calcium gluconate
- B. Sodium bicarbonate
- C. Potassium chloride
- D. Sodium phosphate
Correct Answer: A
Rationale: Calcium gluconate is the correct answer because it is administered to treat hypocalcemia, a common complication post-thyroidectomy. After a thyroidectomy, there is a risk of damaging the parathyroid glands, which can lead to a decrease in calcium levels. Administering calcium gluconate helps to raise calcium levels. Sodium bicarbonate (Choice B) is not typically indicated for immediate postoperative care following a subtotal thyroidectomy. Potassium chloride (Choice C) is not directly related to the common complications of this specific surgery. Sodium phosphate (Choice D) is not typically used to address immediate postoperative issues post-thyroidectomy.
A nurse is planning care for a client who is postoperative following a bowel resection. Which of the following interventions should the nurse include?
- A. Encourage the client to drink adequate fluids daily.
- B. Administer pain medication as needed.
- C. Instruct the client to splint the incision with a pillow.
- D. Encourage the client to eat a balanced diet.
Correct Answer: C
Rationale: The correct intervention for a client post-bowel resection is to instruct the client to splint the incision with a pillow. This technique helps prevent dehiscence, which is the separation of wound edges, and reduces pain when coughing or moving. Splinting supports the incision site, decreasing tension on the wound. Encouraging the client to drink adequate fluids promotes hydration and aids in recovery, but a specific volume like 1,000 mL mentioned in choice A is not essential. Pain medication should be administered as needed for adequate pain control, not necessarily before every meal. Instructing the client to eat a balanced diet, including adequate protein, is crucial for wound healing and overall recovery, rather than limiting protein intake.
A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. Take the medication with food to reduce stomach upset.
- B. Store the medication in a cool, dry place.
- C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
- D. This medication may cause drowsiness.
Correct Answer: C
Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.
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.
A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the nurse indicates an understanding of the teaching?
- A. Stands with feet shoulder-width apart when lifting a client up in bed.
- B. Raises the client's knees before pulling the client up in bed.
- C. Uses a mechanical lift to move a client from bed to chair.
- D. Places a gait belt around the client's waist before assisting the client to stand.
Correct Answer: C
Rationale: Using a mechanical lift is an appropriate ergonomic technique as it reduces the risk of injury to both the nurse and the client by promoting safe client handling practices. Choice A is incorrect as standing with feet shoulder-width apart provides better balance and stability during lifting. Choice B is incorrect as raising the client's knees is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's waist is a safety measure but does not specifically demonstrate an understanding of ergonomic principles.