,⩥ A nurse is planning care for a client who has bipolar disorder and is
experiencing mania. Which of the following interventions should the
nurse include in the plan of care?
1. Encourage the client to participate in group therapy.
2. Instruct the client to avoid napping during the day.
3. Offer the client high-calorie finger foods frequently.
4. Decrease the client's daily fiber intake. Answer: Correct = 3. Offer the
client high-calorie finger foods frequently.
The nurse should frequently offer the client high-calorie foods that can
be eaten while the client is on the go. Clients experiencing mania might
be unable to sit down for meals and can experience weight loss and
dehydration.
*The nurse should maintain a low-stimuli environment for a client who
is experiencing mania. The nurse should dim the lights, decrease noise,
and limit the number of people the client is around. The nurse should
encourage the client to take frequent rest periods throughout the day.
Clients experiencing mania are at risk of exhaustion that can be life
threatening. The nurse should encourage the client to eat foods and
snacks that are high in fiber. Clients experiencing mania can experience
dehydration and nutritional deficiencies from decreased intake, which
can lead to constipation.
⩥ A nurse is assessing a client who has borderline personality disorder.
,Which of the following findings should the nurse expect?
1. Emotional lability
2. Self-sacrificing
3. Suspicious of others
4. Grandiosity. Answer: Correct = 1. Emotional Lability
Emotional lability is the rapid transition from one emotion to another
and is a primary feature of borderline personality disorder. Clients who
have borderline personality disorder react to situations with emotional
responses that are out of proportion to the circumstances.
*Self-Sacrificing, Excessively Clingy and Submissive: Features of
Dependent Personality Disorder
*Suspicious of Others, Project Blame onto Others, Hostile and Violent:
Features of Paranoid Personality Disorder
*Grandiosity, Exploitive, Filled with Rage, and Sensitive to Criticism:
Features of Narcissistic Personality Disorder
⩥ A nurse is caring for an older adult client who begins to cry and states,
"I knew God would punish me and I deserve this horrible sickness!".
Which of the following responses should the nurse make?
1. "Why do you think you deserve this punishment?"
, 2. "Don't worry about being punished by God."
3. "Let's talk about what is upsetting you."
4. "You shouldn't say things that will upset you so much.". Answer:
Correct = 3. "Let's talk about what is upsetting you."
The nurse is acknowledging the client's concerns and is showing a desire
to understand what the client is thinking and feeling.
⩥ A nurse is preparing to administer diazepam 7.5mg IV Bolus to a
client for alcohol withdrawal. Available is diazepam injection 5mg/1mL.
How many mL should the nurse administer? (Round the answer to the
nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).
Answer: Correct = 1.5mL
Follow these steps for the Dimensional Analysis method of calculation:
Step 1: What is the unit of measurement the nurse should calculate?
(Place the unit of measure being calculated on the left side of the
equation.)
XmL =
Step 2: Determine the ratio that contains the same unit as the unit being
calculated. (Place the ratio on the right side of the equation, ensuring
that the unit in the numerator matches the unit being calculated.)
X mL = 1mL/5mg
Step 3: Place any remaining ratios that are relevant to the item on the
right side of the equation, along with any needed conversion factors, to
cancel out unwanted units of measurement.
experiencing mania. Which of the following interventions should the
nurse include in the plan of care?
1. Encourage the client to participate in group therapy.
2. Instruct the client to avoid napping during the day.
3. Offer the client high-calorie finger foods frequently.
4. Decrease the client's daily fiber intake. Answer: Correct = 3. Offer the
client high-calorie finger foods frequently.
The nurse should frequently offer the client high-calorie foods that can
be eaten while the client is on the go. Clients experiencing mania might
be unable to sit down for meals and can experience weight loss and
dehydration.
*The nurse should maintain a low-stimuli environment for a client who
is experiencing mania. The nurse should dim the lights, decrease noise,
and limit the number of people the client is around. The nurse should
encourage the client to take frequent rest periods throughout the day.
Clients experiencing mania are at risk of exhaustion that can be life
threatening. The nurse should encourage the client to eat foods and
snacks that are high in fiber. Clients experiencing mania can experience
dehydration and nutritional deficiencies from decreased intake, which
can lead to constipation.
⩥ A nurse is assessing a client who has borderline personality disorder.
,Which of the following findings should the nurse expect?
1. Emotional lability
2. Self-sacrificing
3. Suspicious of others
4. Grandiosity. Answer: Correct = 1. Emotional Lability
Emotional lability is the rapid transition from one emotion to another
and is a primary feature of borderline personality disorder. Clients who
have borderline personality disorder react to situations with emotional
responses that are out of proportion to the circumstances.
*Self-Sacrificing, Excessively Clingy and Submissive: Features of
Dependent Personality Disorder
*Suspicious of Others, Project Blame onto Others, Hostile and Violent:
Features of Paranoid Personality Disorder
*Grandiosity, Exploitive, Filled with Rage, and Sensitive to Criticism:
Features of Narcissistic Personality Disorder
⩥ A nurse is caring for an older adult client who begins to cry and states,
"I knew God would punish me and I deserve this horrible sickness!".
Which of the following responses should the nurse make?
1. "Why do you think you deserve this punishment?"
, 2. "Don't worry about being punished by God."
3. "Let's talk about what is upsetting you."
4. "You shouldn't say things that will upset you so much.". Answer:
Correct = 3. "Let's talk about what is upsetting you."
The nurse is acknowledging the client's concerns and is showing a desire
to understand what the client is thinking and feeling.
⩥ A nurse is preparing to administer diazepam 7.5mg IV Bolus to a
client for alcohol withdrawal. Available is diazepam injection 5mg/1mL.
How many mL should the nurse administer? (Round the answer to the
nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.).
Answer: Correct = 1.5mL
Follow these steps for the Dimensional Analysis method of calculation:
Step 1: What is the unit of measurement the nurse should calculate?
(Place the unit of measure being calculated on the left side of the
equation.)
XmL =
Step 2: Determine the ratio that contains the same unit as the unit being
calculated. (Place the ratio on the right side of the equation, ensuring
that the unit in the numerator matches the unit being calculated.)
X mL = 1mL/5mg
Step 3: Place any remaining ratios that are relevant to the item on the
right side of the equation, along with any needed conversion factors, to
cancel out unwanted units of measurement.
