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A 27-year-old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care?
- A. Schedule noncompetitive activities that can be carried out alone.
- B. Monitor her decision-making process.
- C. Encourage her to identify feelings of anger.
- D. Provide a structured environment with little stimuli.
Correct Answer: D
Rationale: Clients in the manic phase of bipolar disorder require a structured environment with decreased stimuli to help manage their symptoms. Providing a structured environment with little stimuli (D) can help reduce the risk of escalating behaviors. Scheduling noncompetitive activities that can be carried out alone (A) is more appropriate than group activities as excessive stimuli should be avoided. Monitoring decision-making processes (B) is important due to impulsivity in manic phases. Encouraging the client to identify feelings of anger (C) is not the priority in managing manic symptoms, as it is more often associated with depression than bipolar disorder.
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A client is on a methadone maintenance program for opioid addiction. What is the most important assessment to perform?
- A. Monitor for signs of withdrawal.
- B. Assess for signs of methadone toxicity.
- C. Evaluate the client's respiratory status.
- D. Check the client's blood pressure regularly.
Correct Answer: C
Rationale: The most important assessment to perform for a client on a methadone maintenance program is to evaluate the client's respiratory status. Methadone can cause respiratory depression as a side effect, making it crucial to monitor the client's breathing to prevent potential complications. Monitoring for signs of withdrawal (choice A) is important but not the most critical in this scenario. Assessing for signs of methadone toxicity (choice B) is relevant, but respiratory status takes precedence due to the risk of respiratory depression. Checking the client's blood pressure regularly (choice D) is important for overall assessment but is not as crucial as monitoring respiratory status in this case.
A female client with severe depression who has been on antidepressants for two weeks suddenly becomes more energetic and talkative. What action should the RN take first?
- A. Encourage the client to participate in group activities.
- B. Monitor the client closely for signs of suicidal behavior.
- C. Praise the client for the apparent improvement.
- D. Discuss the client's progress with the healthcare provider.
Correct Answer: B
Rationale: A sudden increase in energy and talkativeness in a client with severe depression who has been on antidepressants for a short period may indicate an increased risk of suicide due to the potential shift from profound sadness to motivation to act. The first action the RN should take is to monitor the client closely for signs of suicidal behavior. Encouraging participation in group activities or praising the client for the apparent improvement may overlook the potential risk of suicidal behavior. While discussing the client's progress with the healthcare provider is important, the immediate concern is to ensure the client's safety by closely monitoring for any signs of suicidal ideation or behavior.
A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?
- A. The emergency room nurse.
- B. His case manager.
- C. The clinic healthcare provider.
- D. His support group sponsor.
Correct Answer: B
Rationale: The case manager (B) is responsible for coordinating community services, making them the best person to refer the client to first as they can describe available treatment options. The emergency room nurse (A) is unnecessary unless the client's behaviors pose imminent threats. The clinic healthcare provider (C) and support group sponsor (D) may be useful but coordinating a treatment program tailored to the client's needs is the priority in this scenario.
The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?
- A. Ineffective denial related to situational anxiety.
- B. Ineffective coping related to inadequate support.
- C. Social isolation related to difficult interactions.
- D. Self-care deficit related to cognitive impairment.
Correct Answer: A
Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.
A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, 'Because he made me mad!' Which goal is best for the nurse to include in the client's plan of care? The client will
- A. outline methods for managing anger.
- B. control impulsive actions toward self and others.
- C. verbalize feelings when anger occurs.
- D. recognize consequences for behaviors exhibited.
Correct Answer: B
Rationale: In this scenario, the client's response indicates poor impulse control, a common issue in individuals with bipolar disorder. The most critical goal for the nurse to include in the client's plan of care is to help the client control impulsive actions toward self and others. This goal is essential for preventing harmful behaviors and mitigating the social consequences associated with impulsivity. While outlining methods for managing anger, verbalizing feelings when anger occurs, and recognizing consequences for behaviors exhibited are important aspects of therapy, they do not directly address the urgent need to control impulsive behavior in this case.