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A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?
- A. Monitor physiological functioning.
- B. Provide a subdued environment.
- C. Supervise personal hygiene.
- D. Observe for mood changes.
Correct Answer: B
Rationale: A subdued environment reduces stimulation, aiding energy conservation. Other options are less directly related to this goal.
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Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical?
- A. Arthritis
- B. Epilepsy
- C. Exercise-induced asthma
- D. Congestive heart failure
Correct Answer: D
Rationale: Congestive heart failure and diuretic use complicate fluid balance, increasing lithium toxicity risk. Other conditions do not directly affect lithium monitoring.
What is the focus of outcome identification for the treatment plan of a patient presenting with grandiose thinking associated with acute mania?
- A. Maintaining an interest in the environment
- B. Developing an optimistic outlook
- C. Self-control of distorted thinking
- D. Stabilizing the sleep pattern
Correct Answer: C
Rationale: Controlling grandiose thinking is the primary outcome, as it addresses the core symptom of mania. Other options are less directly related.
This nursing diagnosis applies to a patient experiencing mania: imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. What is the most appropriate outcome related to patient behavior?
- A. Asking staff for assistance with feeding within 4 days
- B. Drinking six servings of a high-calorie, high-protein drink each day
- C. Consistently sitting with others for at least 30 minutes at mealtime within 1 week
- D. Wearing appropriate attire for age and gender within 1 week while in the psychiatric unit
Correct Answer: B
Rationale: High-calorie, high-protein supplements address the nutritional deficit caused by hyperactivity. Other options do not directly ensure adequate caloric intake.
A patient prescribed lithium telephones the nurse at the clinic to say, 'I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?' What instructions should the nurse provide?
- A. Restrict oral fluids for 24 hours and stay in bed.'
- B. Have someone bring you to the clinic immediately.'
- C. Drink a large glass of water with 1 teaspoon of salt added.'
- D. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.'
Correct Answer: B
Rationale: Symptoms suggest lithium toxicity, requiring immediate evaluation. Other options may worsen the condition or delay treatment.
A patient receiving lithium should be assessed for which evidence of early toxicity?
- A. Pharyngitis, mydriasis, and dystonia
- B. Alopecia, purpura, and drowsiness
- C. Diarrhea, thirst, and vomiting
- D. Ascites, dyspnea, and edema
Correct Answer: C
Rationale: Diarrhea, thirst, and vomiting are early signs of lithium toxicity. Other options are unrelated to lithium therapy.