Nokea
During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?
- A. Encourage the client to participate in a quiet activity.
- B. Provide a safe environment and limit stimuli.
- C. Administer a sedative to help the client sleep.
- D. Discuss the consequences of her risky behaviors.
Correct Answer: B
Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.
You may also like to solve these questions
Which interventions should the nurse include in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)
- A. Permit rest periods as needed.
- B. Speaking slowly and simply.
- C. Place the client on suicide precautions.
- D. Allow the client extra time to complete tasks.
Correct Answer: C
Rationale: The correct answer is C, 'Place the client on suicide precautions.' When caring for a severely depressed client with neurovegetative symptoms, it is crucial to permit rest periods as needed, speak slowly and simply, and allow the client extra time to complete tasks. These interventions help in promoting the client's comfort and well-being. Placing the client on suicide precautions may not always be necessary and should be based on a thorough assessment of the client's risk of self-harm. Therefore, it is the intervention that does not universally apply to all clients in this situation.
A client with schizophrenia is being treated with clozapine (Clozaril). What laboratory test is most important for the nurse to monitor?
- A. Liver function tests
- B. Kidney function tests
- C. White blood cell count
- D. Blood glucose levels
Correct Answer: C
Rationale: The correct answer is C: White blood cell count. Clozapine can lead to agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count is crucial to detect this condition early. Choices A, B, and D are incorrect because while liver and kidney function tests are important in monitoring other aspects of health, the most critical concern with clozapine therapy is the risk of agranulocytosis, making monitoring white blood cell count the priority.
An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, 'Where should I stand for the parade?' Which response is best for the nurse to provide?
- A. "You can stand wherever you'd like as long as you stay safe from those in the parade."
- B. "You seem confused because of all the activity in the hall. There is no parade."
- C. "Let's go back to the activity room and see what is going on in there."
- D. "Remember, this is a nursing home, and I am here to help you."
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?
- A. Weight gain.
- B. Sexual dysfunction.
- C. Nausea.
- D. Constipation.
Correct Answer: B
Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.
A client sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?
- A. Exploring the client's ability to function
- B. Exploring the client's potential for self-harm
- C. Inquiring about the client's perception of appraisal of the neighbor's death
- D. Inquiring about and examining the client's feelings that may block adaptive coping
Correct Answer: D
Rationale: During the working phase of the nurse-client relationship, it is crucial for the nurse to inquire about and examine the client's feelings that may hinder adaptive coping. This helps the client process the traumatic event, explore their emotional responses, and identify any barriers to moving forward effectively. Exploring the client's ability to function (Choice A) may be more relevant in the assessment phase, while exploring the client's potential for self-harm (Choice B) is important but may not be the primary focus at this stage. Inquiring about the client's perception of the neighbor's death (Choice C) is valuable, but addressing feelings blocking adaptive coping is essential for therapeutic progress.