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A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?
- A. Redirect the client to appropriate behavior.
- B. Place the client in seclusion for his or her own protection.
- C. Ignore the behavior to avoid reinforcing it.
- D. Tell the client that the behaviors have to stop right now.
Correct Answer: A
Rationale: Redirecting to appropriate behavior is effective and non-confrontational, preventing escalation of manic behavior.
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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 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.
A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
- A. Immediately after a family visit
- B. On the anniversary of significant life events in the client's life
- C. During the first few days after admission
- D. Approximately 2 weeks after starting antidepressant medication
Correct Answer: D
Rationale: The risk of self-harm increases about 2 weeks after starting antidepressants, as energy improves before mood stabilizes.
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.
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.