Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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. Discourage the client from taking a nap during the day.
Choice A rationale: While a consistent sleep schedule is important in the long term, a short nap during the day might be helpful for someone experiencing mania to prevent complete exhaustion, which can worsen symptoms.
B. Weigh the client every 3 to 4 days.
Choice B rationale: Weighing the client every 3 to 4 days (Choice B) might not be as crucial as the other options provided. While changes in weight can occur during mania, this intervention may not be as directly related to managing the acute symptoms of mania as other interventions.
C. Maintain an environment with low stimuli.
Choice C rationale: Maintaining an environment with low stimuli (Choice C) is essential during a manic episode. Clients with mania often experience heightened sensory sensitivity, and reducing environmental stimuli can help decrease agitation and promote a more stable mood.
D. Offer finger foods to the client every 2 hr.
Choice D rationale: A client in a manic episode has increased caloric needs due to constant physical activity but may be unable to sit down for regular meals. Providing finger foods allows them to eat while remaining active.
E. Monitor vital signs every 1 to 2 hr throughout the day.
Mania can cause physiological changes like increased heart rate, blood pressure, and body temperature. Frequent monitoring helps detect potential complications and guide treatment decisions.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Full Explanation
Correct answers: C, D, E
Choice A rationale:
While a consistent sleep schedule is important in the long term, a short nap during the day might be helpful for someone experiencing mania to prevent complete exhaustion, which can worsen symptoms.
Choice B rationale:
Weighing the client every 3 to 4 days (Choice B) might not be as crucial as the other options provided. While changes in weight can occur during mania, this intervention may not be as directly related to managing the acute symptoms of mania as other interventions.
Choice C rationale:
Maintaining an environment with low stimuli (Choice C) is essential during a manic episode. Clients with mania often experience heightened sensory sensitivity, and reducing environmental stimuli can help decrease agitation and promote a more stable mood.
Choice D rationale:
A client in a manic episode has increased caloric needs due to constant physical activity but may be unable to sit down for regular meals. Providing finger foods allows them to eat while remaining active.
Choice E rationale:
Mania can cause physiological changes like increased heart rate, blood pressure, and body temperature. Frequent monitoring helps detect potential complications and guide treatment decisions.
Similar Questions
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing?
A. Developmental.
Developmental crisis refers to a predictable event in a person's life that is associated with a developmental milestone, such as adolescence or marriage. This crisis is not related to a developmental stage, as it involves an unexpected event.
B. Adventitious.
Adventitious crisis occurs due to extraordinary events that are not part of everyday life, such as accidents, natural disasters, or sudden loss. In this case, the sudden death of the client's wife is an unexpected and distressing event, leading to an adventitious crisis.
C. Situational.
Situational crisis is triggered by a specific event or situation that disrupts a person's psychological equilibrium. While the situation the client is facing is indeed a crisis, it is not the result of an immediate situation; rather, it is caused by an unexpected event.
D. Maturational.
Maturational crisis involves challenges that arise during transitions between stages of life, such as entering adulthood or becoming a parent. The client's crisis does not stem from a developmental transition but rather from the unexpected loss of his wife.
A nurse is preparing a client who has chronic anxiety for discharge from the psychiatric unit. Which of the following instructions should the nurse include in the client's discharge plan?
A. Identify anxiety-producing situations.
This option is the correct choice because helping the client identify anxiety-producing situations empowers the client with the tools to manage anxiety. By recognizing triggers, the client can develop coping strategies to navigate these situations effectively.
B. Contact the crisis counselor once a week.
Contacting a crisis counselor once a week might be helpful, but it is not a comprehensive strategy for managing chronic anxiety. The main focus should be on equipping the client with skills to handle anxiety rather than relying solely on external support.
C. Eliminate stress and anxiety from daily life.
Completely eliminating stress and anxiety from daily life is unrealistic and not achievable. Stress and anxiety are part of human existence, and the goal should be to manage and cope with them rather than attempting to eliminate them entirely.
D. Try to repress feelings of anxiety.
Repressing feelings of anxiety is an unhealthy coping mechanism. Suppressing emotions can lead to further emotional distress and potential exacerbation of anxiety symptoms. Encouraging the client to acknowledge and manage their anxiety is a more effective approach.
A nurse is making a home visit for a 16-year old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
A. Stating that he wants to be with his peers more than with his parents.
Wanting to spend time with peers is not inherently indicative of continued suicidal intent. Adolescents often seek social connections, and while this behavior should be monitored, it is not a specific indicator of ongoing suicidal ideation.
B. Telling his parents that he doesn't want to talk about the suicide attempt.
While reluctance to discuss the event can be a concern, it doesn't automatically translate to continued suicidal thoughts.
C. Preferring to eat his meals while watching TV.
Preferring to eat meals while watching TV is a relatively common behavior and does not directly correlate with suicidal intent. While changes in behavior should be noted, this alone is not a strong indicator of continued risk.
D. Planning to give his CD collection to his girlfriend.
Giving away prized possessions, especially to loved ones, can sometimes be a sign of hopelessness or finality associated with suicidal ideation. It suggests the adolescent may be putting their affairs in order.
Full Explanation
A-Wanting to spend time with peers is not inherently indicative of continued suicidal intent. Adolescents often seek social connections, and while this behavior should be monitored, it is not a specific indicator of ongoing suicidal ideation.
B-While reluctance to discuss the event can be a concern, it doesn't automatically translate to continued suicidal thoughts.
C-Preferring to eat meals while watching TV is a relatively common behavior and does not directly correlate with suicidal intent. While changes in behavior should be noted, this alone is not a strong indicator of continued risk.
D-Giving away prized possessions, especially to loved ones, can sometimes be a sign of hopelessness or finality associated with suicidal ideation. It suggests the adolescent may be putting their affairs in order.