Nokea
A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?
- A. Decrease the client's environmental stimuli.
- B. Give the client feedback about his behavior.
- C. Introduce the client to other staff on the unit.
- D. Tell the client about hospital rules and policies.
Correct Answer: A
Rationale: Reducing environmental stimuli is the priority to help calm an agitated client with bipolar disorder.
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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 nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
- A. The client will avoid causing harm to others.
- B. The client will be free from stress.
- C. The client will independently carry out activities of daily living.
- D. The client will not experience agitation.
Correct Answer: C
Rationale: Independently performing activities of daily living is a realistic and appropriate outcome for a client with depression.
A client who is manic states, 'What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?' Which would be the most appropriate response by the nurse?
- A. Please slow down. I'm not sure what you need first.
- B. You will have to be quiet and have breakfast after the doctor comes.
- C. Are you hungry?
- D. Your thoughts seem to be racing this morning.
Correct Answer: A
Rationale: Asking the client to slow down facilitates communication without blaming, addressing their pressured speech.
A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply.
- A. Weigh self weekly at the same time of day.
- B. Drink a 2-L bottle of decaffeinated fluid daily.
- C. Do not alter dietary salt intake.
- D. See the doctor if you get the flu.
- E. Restrict involvement in intense exercise.
Correct Answer: B,C,D
Rationale: Maintaining fluid intake, stable salt levels, and monitoring for illness prevent lithium toxicity and ensure therapeutic levels.
Which variables represent the highest risk for developing major depressive disorder? Select all that apply.
- A. Male gender
- B. Mood disorder in first-degree relatives
- C. Substance abuse
- D. Divorced
- E. Older adult
Correct Answer: B,D
Rationale: Family history of mood disorders and being single or divorced increase the risk of major depressive disorder.