Nokea
A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?
- A. Administering a sedative that has been prescribed to be used PRN.
- B. Insisting the client take a time-out in his room.
- C. Clearing the area of all other clients.
- D. Setting limits on aggressive and intimidating behavior.
Correct Answer: D
Rationale: Setting limits on aggressive behavior is the initial action to ensure safety while allowing the client to exercise self-control.
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Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide?
- A. The relative's suicide offers a sense of permission or acceptance of suicide as a method of escaping a difficult situation.
- B. Many people with depression who have suicidal ideation lack the energy to implement suicide plans, but antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation.
- C. Suicide is more likely to occur in April when natural energy from increased sunlight may give the client the energy to act on suicidal ideation.
- D. The relative's suicide caused the family members to realize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide.
Correct Answer: A
Rationale: A relative's suicide may normalize the act, increasing risk by providing a sense of acceptability.
A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of his favorite soda. Which action should the nurse take at this time?
- A. Confiscate the soda can as a restricted item.
- B. Pour the soda into a plastic cup.
- C. Ask the visitor to place the soda can at the nurse's desk until he or she leaves.
- D. Ask the visitor not to bring outside items on the unit in the future.
Correct Answer: B
Rationale: Pouring the soda into a plastic cup ensures safety by removing a potential self-harm item while allowing the client to enjoy the drink.
The client with mania attempts to hit the nurse. Which is the best response by the nurse?
- A. Do not swing at me again. If you cannot control yourself, we will help you.
- B. If you do that one more time, you will be put in seclusion immediately.
- C. Stop that. I didn't do anything to provoke an attack.
- D. Why do you continue that kind of behavior? You know I won't let you do it.
Correct Answer: A
Rationale: This response sets clear behavioral expectations and ensures safety without escalating the situation.
Which meal would the nurse provide to best meet the nutritional needs of a client who is manic?
- A. Peanut butter sandwich, chips, cola
- B. Fried chicken, mashed potatoes, milk
- C. Ham sandwich, cheese slices, milk
- D. Spaghetti, garlic bread, salad, tea
Correct Answer: C
Rationale: Finger foods like a ham sandwich and cheese slices are high in calories and protein, suitable for a manic client's mobility.
Which client is at highest risk for carrying out a suicide plan?
- A. A client who plans to take a bottle of sleeping pills.
- B. A client who says, 'My life is over.'
- C. A client who has a private gun collection.
- D. A client who says, 'I'm going to jump off the next bridge I see.'
Correct Answer: C
Rationale: Access to a lethal means like a gun collection significantly increases the likelihood of completing a suicide plan.