Page 2588 - Saunders Comprehensive Review For NCLEX-RN

872. Answer: 4

Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity,
excessive energy, decreased need for sleep, and impaired ability to concentrate or
complete a single train of thought. The client’s mood is predominantly elevated,
expansive, or irritable. All of the options reflect a client’s possible symptoms.
However, the correct option clearly presents a problem that compromises
physiological integrity and needs to be addressed immediately.
Test-Taking Strategy: Note the strategic word, immediate, and use Maslow’s
Hierarchy of Needs theory to assist you in answering the question. The correct
option is the only one that reflects a physiological need.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Mental Health
Health Problem: Mental Health: Mood disorders
Priority Concepts: Psychosis; Safety
Reference: Varcarolis (2017), pp. 227, 229.

873. Answer: 3

Rationale: Clients who are admitted involuntarily to a mental health unit do not
lose their right to informed consent. Clients must be considered legally competent
until they have been declared incompetent through a legal proceeding. The best
determination for the nurse to make is to obtain the informed consent from the
client.
Test-Taking Strategy: Focus on the subject, informed consent for an involuntarily
admitted client, and note the strategic word, best. Knowledge regarding the hospital
admission processes and client’s rights will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Planning
Content Area: Leadership/Management: Ethical/Legal
Health Problem: Mental Health: Mood disorders
Priority Concepts: Ethics; Health Care Law
Reference: Varcarolis (2017), p. 63.

874. Answer: 3

Rationale: Glucagon is used to treat hypoglycemia resulting from insulin
overdose. The family of the client is instructed in how to administer the medication.
In an unconscious client, arousal usually occurs within 20 minutes of glucagon
injection. When consciousness has been regained, oral carbohydrates should be
given. Lipoatrophy and lipohypertrophy result from insulin injections.
Test-Taking Strategy: Focus on the subject, the purpose of glucagon. Also note
the strategic word, best. Noting the word glucagon will assist you in determining
that the medication contains some form of glucose. This relationship will direct you

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