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A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
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A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client?
- A. Assign the client a new task to master.
- B. Turn on the television to a musical program.
- C. Make the client aware that the behavior is undesirable.
- D. Talk about the family pictures on display in the client's room.
Correct Answer: D
Rationale: Providing familiar objects will decrease anxiety. Decreasing environmental stimuli also aids in reducing agitation for the head-injured client. Option 1 does not simplify the environment because a new task may be frustrating. Option 2 increases stimuli. In option 3 the nurse uses negative reinforcement to help the client adjust.
A client experiencing urticaria (hives) and pruritus states to the nurse, 'What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy.' Which statement made by the nurse is the most therapeutic?
- A. You're troubled that this will extend into your wedding?
- B. It's probably just due to prewedding jitters. You'll be fine.
- C. The antihistamine will help a great deal, just you wait and see.
- D. Do you think this would really be something that could ruin your wedding?
Correct Answer: A
Rationale: The therapeutic communication technique that the nurse uses in option 1 is reflection. In option 2, the nurse minimizes the client's anxiety and fears. In option 3, the nurse talks about antihistamines and asks the client to 'wait and see.' This is nontherapeutic because the nurse is making promises that may not be kept. In addition, the response is closed-ended and shuts off the client's expression of feelings. In option 4, the nurse responds without sensitivity.
The nurse manager of the psychiatric unit plans the biweekly, unit-wide interdisciplinary team case conference focused on one particular client. Which client is most important for the manager to select for discussion?
- A. A client who was admitted after a second serious suicide attempt and refuses to talk.
- B. A client toward whom the staff have sharply conflicting attitudes and actions.
- C. A client who experiences hallucinations, takes possessions from other clients, and paces continually.
- D. A client, well known and well liked by staff, whose diagnostic testing reveals a brain tumor.
Correct Answer: A
Rationale: A client with a recent serious suicide attempt who refuses to talk is at high risk for self-harm and requires urgent interdisciplinary discussion to coordinate safety and treatment plans. Other cases, while significant, are less immediately life-threatening.
A nurse in the outpatient clinic receives four phone messages. Which call does the nurse return first?
- A. The parent of a preschool-age child who continuously throws temper tantrums, is always moving, and is impulsive.
- B. The parent whose adolescent child has vomited every day for 2 weeks and now weighs 74 pounds.
- C. The parent who receives calls from the school about an adolescent child's aggressive behavior toward schoolmates.
- D. The adult child of an older adult who is having difficulty sleeping after a spouse died 2 weeks ago.
Correct Answer: B
Rationale: An adolescent vomiting daily for 2 weeks and weighing 74 pounds indicates a critical health issue, likely severe dehydration or malnutrition, requiring urgent assessment to prevent life-threatening complications. This takes priority over behavioral, aggression, or grief-related concerns.
The nurse is caring for a client who has been diagnosed with terminal pancreatic cancer. The family is asking what to expect when the end draws near. Which response by the nurse is most appropriate?
- A. I will have the doctor talk to you about that.
- B. The hospice nurse is the best person to answer your questions. I can put in a consult for you.
- C. Don't worry about that right now. You don't know if there is another treatment option that will work.
- D. I can tell you what to look for when the time comes. In the meantime, what are your wishes and goals for care?
Correct Answer: D
Rationale: This response addresses the family's question while opening a discussion about care goals, which is supportive and appropriate.