a nurse is planning care for a client who is experiencing acute mania what intervention should the nurse include
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

2. A nurse is providing teaching to a client who has a new prescription for atorvastatin. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Avoid drinking grapefruit juice while taking this medication.' Grapefruit juice can increase the risk of toxicity when taken with atorvastatin. Choice B is incorrect because atorvastatin should be taken without regard to meals. Choice C is incorrect because atorvastatin can be taken at any time of the day. Choice D is incorrect because atorvastatin does not need to be taken on an empty stomach.

3. How should bleeding in a patient on warfarin be monitored?

Correct answer: A

Rationale: The correct answer is to monitor INR levels. INR levels are the most critical indicator for monitoring bleeding risk in patients on warfarin. INR stands for International Normalized Ratio and specifically measures the clotting tendency of the blood. Monitoring hemoglobin levels, potassium levels, or platelet count are not as directly relevant to assessing bleeding risk in patients on warfarin.

4. A nurse is planning care for a client with thrombocytopenia. Which action should be included?

Correct answer: C

Rationale: The correct action to include in the care plan for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent straining during bowel movements, reducing the risk of bleeding episodes. Encouraging the client to floss daily (choice A) is important for oral hygiene but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (choice B) is more relevant for clients with neutropenia to reduce the risk of infection. Avoiding serving the client raw vegetables (choice D) is important for clients with compromised immune systems but is not specifically related to thrombocytopenia.

5. A nurse is providing discharge teaching to a client who has had a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C because bending at the hips can dislocate the hip joint in clients who have had a total hip arthroplasty. This movement should be avoided to prevent complications post-surgery. Choices A, B, and D are all correct statements for a client who has had a total hip arthroplasty. Avoiding prolonged sitting, crossing legs, and using a raised toilet seat are all appropriate measures to ensure proper healing and prevent complications.

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