Nurse Ben performs Susan Choi's initial mental status assessment. Which of the following categories indicates correct nursing assessment findings? (You will find hot spots to select in the artwork below.
answer
​The client is experiencing a manic episode with inappropriate responses that are not within appropriate limits. (Grandulose thinking)
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Nurse Ben and the nursing staff conduct a care planning conference to discuss nursing actions to promote Susan Choi's recovery. Which of the following nursing actions should Ben implement? (Select all that apply.)
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Using a firm, calm, matter-of-fact approach can provide structure and offer security to a client who is feeling out of control. Offering high-calorie drinks can compensate for increased caloric expenditures during hyperactivity and prevent serious dehydration. Decreasing light, noise, and interactions can minimize anxiety and agitation. Using distraction to redirect the client to constructive behaviors makes positive use of the client's distractibility. Use of open-ended statements does not provide structure or direction for a client experiencing a manic episode. Encouraging competitive activities can increase excitability and evoke angry outbursts.
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Nurse Ben develops an initial meal plan for Susan Choi and is preparing to discuss the plan with Susan and her mother. Which of the following menus represents an appropriate diet for Susan? (Select the appropriate image.)
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A client who is experiencing a manic episode is hyperactive and typically unable to sit for meals. This meal offers "finger foods," and a non-caffeinated beverage, which the client can consume while moving around. But the bagel could be difficult to chew and a peach is messy when eaten. The meal also offers high-protein, high-calorie foods with no utensils. (option c)
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Nurse Ben is planning care for Susan and is reviewing manifestations of lithium toxicity. The nurse should monitor for which of the following findings?
answer
ataxia
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Nurse Ben reviews Susan Choi's assessment data. Which of the following assessment tools should he use to identify suicide risk factors and the need for hospitalization?
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​SAFE-T
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Nurse Ben is reviewing the adverse effects of lamotrigine. Which of the following is a serious adverse effect of this medication?
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Stevens johnsons syndrome
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Nurse Ben responds to Susan's despondent behavior. Which of the following is an appropriate response by Ben?
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"Do you have a plan for how you would end your life?"
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Nurse Ben is planning discharge outcomes for Susan Choi. Identify client outcomes for Susan in the following areas: lifestyle support/bipolar management, medication management, and crisis management. (Include three or more outcomes for each category.)
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Maintain consistent patterns in sleep, meals, and activities,Take prescribed medication, even when feeling well,Identify signs of bipolar relapse and possible precipitating factors (disturbance in sleep patterns, intake of caffeine, alcohol, drug abuse, and discontinuing prescribed medications)
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Nurse Ben continues to collect information related to Susan Choi's episode of manic behavior. Which of the following responses to the question asked by the client's mother is appropriate?
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"According to the literature, there is strong genetic predisposition for bipolar disorders."
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Susan Choi behaves seductively towards Nurse Ben. Which of the following responses by Ben is appropriate?
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Give clear expectations of behavior
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Nurse Ben is preparing to administer olanzapine to Susan Choi who is in the early phase of acute mania. Which of the following are expected outcomes of the medication? (Select all that apply.)
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A client who receives olanzapine can experience sedation, decreased agitation, and fewer mania relapses. Common side effects of olanzapine include an increase of premenstrual syndrome symptoms and weight gain.
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Nurse Ben is preparing to administe olanzapine 10 mg IM to Susan Choi, who has acute mania. The nurse should reconstitute the medication with 2.1 mL of sterile water to yield 5 mg/mL. How many mL should Ben administer? (Round to the nearest whole number.)
answer
2
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Nurse Ben is attempting to administer the olanzapine (Zyprexa) IM to Susan Choi, but she forcefully refuses it. Which of the following actions should Ben take?
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explain why she needs the medication and why IM
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Nurse Ben is leading a group therapy session and Susan Choi interrupts the session. Which of the following actions should Ben take to manage Susan's disruptive behavior?
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have her escorted from the group
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The admission orders indicate Susan Choi is to have several laboratory tests drawn and to start therapy with lithium. Which of the following laboratory tests must be drawn prior to starting lithium therapy? (Select all that apply.)
answer
Thyroid, Bun/creatine, hcg
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Nurse Ben is preparing to instruct Susan Choi and her family regarding lithium therapy. Which of the following instructions should Ben include in his teaching? (Select all that apply.)
answer
Take the medication with meals. Maintain consistent sodium intake. Consume 2 to 3 L of fluid per day.
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