🍎 Clients experiencing acute mania are often hyperactive, restless, and unable to sit still long enough to eat regular meals. Providing high-calorie, high-protein finger foods allows them to eat while remaining active.

🍎 During manic episodes, clients expend a great deal of energy because of increased physical activity, rapid speech, and decreased need for sleep, placing them at risk for weight loss and dehydration.

🍎 Finger foods such as sandwiches, cheese cubes, fruit slices, granola bars, and crackers are easy to eat while walking or moving around.

🍎 The nurse should also encourage frequent fluids to prevent dehydration and monitor the client's nutritional intake.

🍎 The environment should be calm and low in stimulation to reduce agitation and excessive activity.

🍎 The nurse should use short, simple, and clear communication because clients with mania have difficulty concentrating.

🍎 Safety is a priority, and the nurse should monitor for impulsive or risky behaviors.

🍎 Providing finger foods throughout the day best meets the nutritional needs of a client experiencing acute mania.

❌ Keep the overhead lights on in the client's room.

💡 Clients with mania benefit from a calm, quiet, and low-stimulation environment.

💡 Bright lights and excessive stimulation can increase agitation and manic behaviors.

❌ Encourage the client to participate in group activities.

👥 Group activities may overstimulate the client and increase manic behavior.

👥 One-to-one interactions or brief, low-stimulation activities are more appropriate during acute mania.

❌ Give the client coffee or caffeinated beverages.

☕ Caffeine is a stimulant that can worsen hyperactivity, restlessness, insomnia, and agitation.

☕ Clients with mania should avoid caffeinated beverages.

👶 Children with disabilities, such as cerebral palsy, are at a significantly higher risk for child maltreatment because they often require increased caregiving, supervision, and medical support.

👶 Caring for a child with special healthcare needs can place additional physical, emotional, and financial stress on caregivers, increasing the risk for abuse or neglect.

👶 Children with disabilities may have communication difficulties, making it harder to report abuse or for others to recognize signs of maltreatment.

👶 They may also be more dependent on caregivers for daily activities, increasing their vulnerability.

👶 The nurse should carefully assess for unexplained injuries, delayed treatment for injuries, poor hygiene, malnutrition, fearfulness, or inconsistent caregiver explanations.

👶 Nurses are mandated reporters and must report any reasonable suspicion of child abuse or neglect according to state or local laws.

👶 Early identification and intervention can protect the child and connect the family with appropriate support services.

👶 A toddler with cerebral palsy has the greatest risk for child maltreatment among the options provided.

❌ An adolescent who requests contraception

🩺 Requesting contraception is a common healthcare need among adolescents and does not, by itself, indicate an increased risk for child maltreatment.

🩺 The nurse should provide confidential, age-appropriate reproductive health education and assess for safety concerns if indicated.

❌ A preschooler whose parents report the child often says "no"

🧸 Saying "no" is a normal developmental behavior for preschool-aged children as they seek independence.

🧸 This behavior alone does not increase the child's risk for abuse or neglect.

❌ A school-age child whose parent has generalized anxiety disorder

🧠 A parent with generalized anxiety disorder is not automatically abusive or neglectful.

🧠 While parental mental illness may increase family stress, anxiety disorder alone is not as strong a risk factor for child maltreatment as the child's disability.

🧠 Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety disorders, obsessive-compulsive disorder (OCD), and other psychiatric conditions.

🧠 When initiating fluoxetine, the nurse should closely monitor the client's mental status, especially for worsening depression, increased anxiety, agitation, suicidal thoughts, or unusual behavioral changes.

🧠 The risk of suicidal ideation may temporarily increase during the first few weeks of therapy, particularly in children, adolescents, and young adults.

🧠 The nurse should also monitor for signs of serotonin syndrome, including confusion, agitation, hyperthermia, tremors, muscle rigidity, and autonomic instability, especially if the client is taking other serotonergic medications.

🧠 Clients should be instructed not to discontinue fluoxetine abruptly, as this may cause withdrawal symptoms or relapse of depression.

🧠 The therapeutic effects of fluoxetine usually begin after 2–4 weeks, with full benefits often taking 4–6 weeks or longer.

🧠 Ongoing assessment of mood, sleep, appetite, energy level, and suicidal risk is an essential nursing responsibility throughout treatment.

🧠 Monitoring for changes in mental status is the priority nursing intervention when administering fluoxetine for the first time.

❌ Administer ibuprofen to the client to treat elevated temperature.

🌡️ Ibuprofen is not routinely indicated when starting fluoxetine.

🌡️ If the client develops a fever while taking fluoxetine, the nurse should first assess for serotonin syndrome, a potentially life-threatening adverse reaction, rather than automatically administering an antipyretic.

❌ Observe the client for Chvostek sign.

⚡ Chvostek sign is an assessment for hypocalcemia and is unrelated to fluoxetine therapy.

⚡ It is not a routine assessment for clients taking SSRIs.

❌ Evaluate therapeutic results within 12 hr of administration.

⏳ Fluoxetine does not produce immediate therapeutic effects.

⏳ Clients should be taught that improvement usually occurs after 2–4 weeks, and full therapeutic benefit may take several more weeks.

💙 Encouraging the client to express their feelings is the most therapeutic nursing intervention for a client experiencing anticipatory grief.

💙 Anticipatory grief occurs before an expected loss, such as the progressive decline associated with dementia. Clients and families may grieve the gradual loss of memory, independence, and functioning before death occurs.

💙 The nurse should provide a safe, supportive, and nonjudgmental environment where the client feels comfortable discussing emotions such as sadness, fear, anger, guilt, or frustration.

💙 Allowing clients to verbalize their feelings promotes healthy coping, reduces emotional distress, and helps them process the grieving experience.

💙 The nurse should use active listening, empathy, silence, and open-ended questions while avoiding false reassurance or minimizing the client's emotions.

💙 Grief is an individualized process, and clients should be allowed to grieve at their own pace without pressure or expectations.

💙 Providing emotional support also helps build trust and strengthens the therapeutic nurse-client relationship.

💙 Encouraging emotional expression is a cornerstone of therapeutic nursing care for clients experiencing anticipatory grief.

❌ Provide the client with a timeline for grieving.

⏳ There is no set timeline for grief, and each person's grieving process is unique.

⏳ Telling clients when they should recover may increase anxiety or feelings of failure.

❌ Share personal stories of grief with the client.

🙅 Sharing personal experiences shifts the focus away from the client and is generally nontherapeutic.

🙅 The nurse should keep the conversation centered on the client's feelings and needs.

❌ Show sympathy for the client when discussing their condition.

❤️ Sympathy expresses pity, whereas empathy focuses on understanding and supporting the client's feelings.

❤️ Therapeutic communication emphasizes empathy, not sympathy

🚨 Clients with delirium have the greatest risk for accidents and injury because delirium causes an acute disturbance in attention, awareness, cognition, and perception.

🚨 Delirium develops suddenly and is characterized by confusion, disorientation, impaired judgment, fluctuating levels of consciousness, hallucinations, and difficulty focusing.

🚨 These symptoms significantly increase the risk of falls, wandering, accidental injury, and unsafe behaviors.

🚨 Clients with delirium may become agitated, attempt to remove medical devices, or misinterpret their surroundings, placing themselves and others at risk.

🚨 Nursing priorities include frequent reorientation, close observation, fall precautions, maintaining a safe environment, and treating the underlying cause of the delirium.

🚨 Delirium is considered a medical emergency because it often indicates an acute illness, infection, medication effect, or metabolic disturbance.

🚨 Early recognition and intervention can reduce complications and improve outcomes.

🚨 Among the options, the adolescent with delirium has the highest immediate risk of accident and injury.

❌ A school-age child who has a tic disorder

👦 A tic disorder involves sudden, repetitive motor movements or vocalizations but does not usually impair awareness or judgment.

👦 Although tics may interfere with daily activities, they do not pose the same immediate safety risk as delirium.

❌ A client who has obsessive-compulsive disorder

🧠 Clients with OCD may perform repetitive rituals and experience anxiety, but they generally remain alert and oriented.

🧠 Their risk of accidental injury is much lower than that of a client with delirium.

❌ A client who has a gambling disorder

🎲 Gambling disorder primarily affects financial, occupational, and interpersonal functioning rather than causing immediate physical safety risks.

🎲 It does not typically impair consciousness or judgment to the extent seen in delirium.

😴 Keeping a sleep diary helps the client identify sleep patterns, bedtime routines, factors that interfere with sleep, and behaviors that promote restful sleep.

😴 Clients with depressive disorders commonly experience insomnia, hypersomnia, early morning awakening, or poor sleep quality, making sleep hygiene an important part of treatment.

😴 A sleep diary records bedtime, wake-up time, naps, caffeine intake, exercise, medications, nighttime awakenings, and sleep quality.

😴 Reviewing the diary helps the client and healthcare provider identify behaviors that contribute to sleep disturbances and develop strategies to improve sleep.

😴 The nurse should also teach healthy sleep hygiene, including maintaining a regular bedtime, limiting caffeine and alcohol, avoiding heavy meals before bed, and creating a quiet, dark sleep environment.

😴 Consistent sleep habits can improve mood, concentration, energy level, and overall mental health.

😴 Sleep diaries are a nonpharmacologic, evidence-based intervention that supports long-term management of insomnia associated with depression.

😴 Keeping a sleep diary is the most appropriate intervention to promote a consistent sleep schedule and improve sleep quality.

❌ "Take a 1-hour nap every day."

🛌 Long daytime naps can interfere with nighttime sleep and worsen insomnia.

🛌 If naps are necessary, they should generally be short (20–30 minutes) and not taken late in the day.

❌ "Discontinue any medication until your sleep disruption is addressed."

💊 Clients should never stop prescribed antidepressants or other medications without consulting their healthcare provider.

💊 Abrupt discontinuation may worsen depression or cause withdrawal symptoms.

❌ "Exercise late in the day, preferably before bedtime."

🏃 Regular exercise promotes better sleep, but vigorous exercise immediately before bedtime may increase alertness and delay sleep onset.

🏃 Exercise is generally recommended earlier in the day or at least several hours before bedtime.

🩸 Clozapine

🩸 Clozapine should be clarified before administration because it can cause severe neutropenia or agranulocytosis, which greatly increases the client’s risk for life-threatening infection.

🩸 The client’s WBC count decreased from 5,100/mm³ on day 1 to 4,200/mm³ on day 4, which is below the listed expected range of 5,000–10,000/mm³.

🩸 A declining WBC count suggests that clozapine may be suppressing bone marrow production of infection-fighting white blood cells.

🩸 The nurse should withhold the dose temporarily and contact the provider for further instructions and additional laboratory evaluation.

🩸 In current clinical practice, the absolute neutrophil count (ANC) is the most important laboratory value used to determine whether clozapine can be safely continued.

🩸 The nurse should assess the client for signs of infection, including fever, sore throat, chills, mouth ulcers, weakness, or flu-like symptoms.

🩸 Although the client’s functioning has improved and the auditory hallucinations have decreased, therapeutic improvement does not eliminate the danger associated with possible blood-cell suppression.

🩸 Therefore, the abnormal WBC count is the finding that requires the nurse to clarify the clozapine prescription before giving the medication.

Loratadine — Cough

🌿 Loratadine is a second-generation antihistamine used to manage allergic symptoms such as sneezing, rhinorrhea, itching, and watery eyes.

🌿 A dry cough does not typically indicate a dangerous adverse effect of loratadine and does not require the prescription to be clarified based on the information provided.

Fluoxetine — Anxiety

💊 Fluoxetine is an SSRI prescribed for major depressive disorder and may also be used for several anxiety-related conditions.

💊 Although fluoxetine can initially increase restlessness or anxiety, the client’s anxiety was documented on admission, and the day-4 findings show improved sleep, intake, ADLs, and group participation rather than severe deterioration.

Lorazepam — Auditory hallucinations

😌 Lorazepam is a benzodiazepine used to reduce anxiety, agitation, and acute distress; it is not the primary medication used to treat auditory hallucinations.

😌 Occasional hallucinations indicate that schizophrenia symptoms are still present, but this does not make the PRN lorazepam prescription unsafe or require clarification.

🩸 Neutropenia is one of the most serious adverse effects of clozapine because it significantly reduces the number of neutrophils, the white blood cells responsible for fighting bacterial infections.

🩸 Clozapine can cause bone marrow suppression, leading to neutropenia or the more severe condition known as agranulocytosis, which can become life-threatening if not detected early.

🩸 Clients receiving clozapine require regular monitoring of the white blood cell (WBC) count and absolute neutrophil count (ANC) before and throughout therapy.

🩸 The nurse should monitor for signs of infection such as fever, sore throat, chills, mouth ulcers, or flu-like symptoms, as these may indicate severe neutropenia.

🩸 If the client's WBC or ANC falls below the recommended safe level, the nurse should withhold the medication and notify the healthcare provider immediately.

🩸 Clozapine is often reserved for treatment-resistant schizophrenia because of its effectiveness despite the risk of serious hematologic adverse effects.

🩸 Early recognition of neutropenia can prevent severe infections, sepsis, and potentially fatal complications.

🩸 Neutropenia is the hallmark adverse effect associated with clozapine and requires ongoing laboratory monitoring throughout treatment.

❌ Hypertension

🩺 Hypertension is not a characteristic adverse effect of clozapine.

🩺 Clozapine is more commonly associated with orthostatic hypotension, particularly when therapy is initiated or the dose is increased.

❌ Bradycardia

❤️ Bradycardia is not a common adverse effect of clozapine.

❤️ Clozapine is more frequently associated with tachycardia, especially during the early stages of treatment.

❌ Hypocalcemia

🦴 Hypocalcemia is not associated with clozapine therapy.

🦴 Clozapine does not routinely affect calcium metabolism or serum calcium levels.

🚶 The first nursing intervention for a client who is becoming increasingly angry is to use the least restrictive intervention by walking with the client or encouraging physical activity to help safely reduce tension and agitation.

🚶 Anger does not necessarily mean the client is violent. Early therapeutic interventions can often prevent escalation into aggressive behavior.

🚶 Walking with the client provides an outlet for excess energy while allowing the nurse to continue assessing the client's emotional state.

🚶 During the walk, the nurse should use a calm voice, active listening, and therapeutic communication to encourage the client to express their feelings.

🚶 The nurse should maintain a safe distance, avoid arguing, and remain alert for signs that the client's anger is escalating despite the intervention.

🚶 This intervention follows the principle of using the least restrictive measure first, which is a fundamental standard in psychiatric nursing.

🚶 If the client's behavior continues to escalate or becomes threatening, the nurse should then obtain assistance, administer PRN medication if prescribed, or use seclusion/restraints only as a last resort.

🚶 Walking with the client is the most appropriate initial intervention because it promotes de-escalation while preserving the client's dignity and autonomy.

❌ Place the client in seclusion to prevent them from harming other clients.

🚪 Seclusion is a last-resort intervention used only when the client poses an immediate danger to themselves or others and less restrictive measures have failed.

🚪 It is inappropriate as the first action for a client who is only becoming increasingly angry.

❌ Ensure enough staff are available to assist if the client becomes violent.

👥 Having staff available is important if the client's behavior escalates toward violence.

👥 However, because the client has not yet become violent, the nurse should first attempt therapeutic de-escalation using the least restrictive intervention.

❌ Administer a tranquilizing medication to calm the client down.

💊 Medication may be necessary if nonpharmacological interventions fail or if the client poses an immediate risk of harm.

💊 It should not be the first intervention when less restrictive methods may effectively de-escalate the situation.

🧠 The first nursing action is to assess the client for depression using a validated screening tool such as the Geriatric Depression Scale (GDS).

🧠 Older adults often present with depression differently than younger adults, commonly exhibiting social withdrawal, loss of interest in activities, decreased participation, fatigue, or changes in appetite, rather than expressing sadness.

🧠 The family member's observation that the client no longer participates in social events is a possible sign of depression, making further assessment the priority.

🧠 According to the nursing process, assessment always comes before planning, implementation, or referral unless an immediate life-threatening situation exists.

🧠 The GDS is a reliable screening tool specifically designed to identify depressive symptoms in older adults.

🧠 Early identification of depression allows the healthcare team to initiate appropriate treatment and improve the client's quality of life.

🧠 After completing the assessment, the nurse can determine whether medication review, referrals, or community resources are appropriate.

🧠 Assessing with the Geriatric Depression Scale is the priority because it identifies the underlying cause of the client's social withdrawal before interventions are planned.

❌ Review current prescription medications with the client.

💊 Medication review is important because some medications may contribute to depression or social withdrawal.

💊 However, the nurse should first assess whether depression is present before determining if medications are a contributing factor.

❌ Review activities available at the community center with the client.

🏘️ Encouraging social activities may benefit the client after the underlying cause of withdrawal has been identified.

🏘️ Recommending activities before assessment may overlook untreated depression.

❌ Refer the client to a gerontologist for further evaluation.

👨‍⚕️ Referral may be appropriate after the nurse completes the initial assessment and identifies the client's needs.

👨‍⚕️ Assessment findings should guide the decision to refer.