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A client with bipolar disorder is experiencing a manic episode. Which nursing intervention is most appropriate?
- A. Encourage group activities to decrease isolation.
- B. Provide a structured environment with routine activities.
- C. Limit the client's physical activity to prevent exhaustion.
- D. Allow the client to choose activities freely.
Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder may exhibit excessive energy, impulsivity, and disorganized behavior. Providing a structured environment with routine activities is the most appropriate nursing intervention. This approach can help regulate the client's behavior, reduce impulsivity, and prevent engaging in potentially harmful activities. Encouraging group activities (Choice A) may exacerbate the client's symptoms due to overstimulation. Limiting physical activity (Choice C) may not address the need for structure and routine during a manic episode. Allowing the client to choose activities freely (Choice D) can lead to impulsive decision-making and may not provide the necessary boundaries required to manage the manic symptoms effectively.
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The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?
- A. What do you believe the news commentator said to you?
- B. Let's switch to a different news channel.
- C. Is the news commentator planning to harm you or others?
- D. The news commentator is not communicating with you.
Correct Answer: A
Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?
- A. Claustrophobia.
- B. Acrophobia.
- C. Agoraphobia.
- D. Necrophobia.
Correct Answer: C
Rationale: The correct answer is C, Agoraphobia. Agoraphobia involves the fear of situations where escape might be difficult, often leading to the individual avoiding public spaces or leaving their home. In this case, the client's reluctance to leave home, not going to work, and staying indoors for an extended period align with the symptoms of agoraphobia. Choices A, B, and D are incorrect. Claustrophobia is the fear of confined spaces, acrophobia is the fear of heights, and necrophobia is the fear of death or dead things, none of which are consistent with the client's symptoms described in the scenario.
An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?
- A. Information regarding shelters
- B. Instructions regarding calling the police
- C. Instructions regarding self-defense classes
- D. Explaining the importance of leaving the violent situation
Correct Answer: A
Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.
Unresolved feelings related to loss are most likely to be recognized during which phase of the therapeutic nurse-client relationship?
- A. Working
- B. Trusting
- C. Orientation
- D. Termination
Correct Answer: D
Rationale: Unresolved feelings related to loss are often recognized and explored during the termination phase of the nurse-client relationship. This phase involves preparing the client for separation from the nurse, which can trigger unresolved feelings related to loss. During the termination phase, clients may confront their emotions about ending the therapeutic relationship and may also revisit unresolved issues or losses that have surfaced during the course of therapy. Choices A, B, and C are incorrect because the working phase focuses on active problem-solving and goal achievement, the trusting phase emphasizes establishing rapport and building trust, and the orientation phase involves initial introductions and orientation to the therapeutic process, respectively.
A client who has been diagnosed with borderline personality disorder is exhibiting manipulative behavior. What is the most important intervention for the LPN/LVN to implement?
- A. Set clear, consistent limits on manipulative behavior.
- B. Ignore the manipulative behavior to avoid reinforcing it.
- C. Remind the client that manipulative behavior is unacceptable.
- D. Explain the consequences of manipulative behavior to the client.
Correct Answer: A
Rationale: Setting clear, consistent limits on manipulative behavior is the most important intervention for a client diagnosed with borderline personality disorder. This approach helps establish boundaries, maintain a therapeutic environment, and provide structure for the client. Choice B is incorrect because ignoring manipulative behavior can lead to its reinforcement. Choice C, while important, may not be as effective as directly setting limits. Choice D focuses on consequences rather than immediate intervention, making it less effective than setting clear limits.