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A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?
- A. I understand that you're angry and unhappy. Let's explore ways in which you overreact
- B. I hear your frustration about losing control. Tell me how this affects your daily life
- C. Knowing the cause of your symptoms will make them easier to handle
- D. Do all that you can to learn all that you can while you are here. You can get better
Correct Answer: B
Rationale: This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship. The first option may invalidate feelings by assuming overreaction. The third shifts focus from immediate concerns. The fourth is encouraging but does not address current feelings.
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Nurses' Notes
• Diagnosis: depression and post-traumatic stress disorder Diphenhydramine 12.5 mg PO every night at sleep (HS) • Buspirone hydrochloride 7.5 mg PO twice a day
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash.
During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. The statement by the client represents and should be followed up with an
- A. suicidal ideation, assessment of risk factors for suicide
Correct Answer: A
Rationale: The client's statement reflects suicidal ideation, requiring immediate assessment of suicide risk factors (e.g., history, stressors, support systems) to determine appropriate interventions, ranging from monitoring to psychiatric evaluation.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone. When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Administer the prescribed anticholinergic benztropine for dystonia
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms
- C. Direct the client to occupational therapy to distract him from somatic complaints
- D. Medicate the client with the prescribed antipsychotic thioridazine
Correct Answer: A
Rationale: The client's laterally contracted position and perception of contortion suggest acute dystonia, a side effect of risperidone. Benztropine, an anticholinergic, alleviates dystonia. Hot packs, occupational therapy, or thioridazine do not address this acute reaction.
During a family group meeting, the client's daughter tells the group, 'I hope I didn't cause Mom to be depressed.' Which response is best for the nurse to provide?
- A. I hear you say you worry about causing your mother's distress
- B. Are you afraid that your mother's depression will lead to her death?
- C. What do you think you did that led to your mother's depression?
- D. You are not alone in feeling responsible for others in your family
- E. You are not alone in feeling responsible for others in your family
Correct Answer: A
Rationale: This response acknowledges the daughter's feelings without assumptions or blame, fostering open communication. The second option escalates anxiety. The third may encourage self-blame. The fourth generalizes without addressing her specific concern.
An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?
- A. Reinforce the need for the adolescent to attend group therapy sessions
- B. Tell the mother to describe her feelings of helplessness to her child
- C. Advise the mother to call the police if violent behavior occurs again
- D. Refer the mother for psychiatric evaluation for anxiety and depression
Correct Answer: C
Rationale: Advising the mother to call the police if violent behavior recurs prioritizes safety for the adolescent and household. Therapy attendance is important but secondary to immediate safety. Discussing the mother's feelings or referring her for evaluation does not address the acute risk.