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A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?
- A. As soon as lunch is over, the client will calm down.
- B. Other clients need to be protected from the intrusive behavior.
- C. The client's behavior is not an imminent threat to anyone's physical safety.
- D. The client needs food and fluids in any way possible.
Correct Answer: B
Rationale: Protecting other clients from intrusive behavior upholds their rights and maintains a safe environment.
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A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate?
- A. Allowing the client to direct her participation at her own pace.
- B. Giving the client several choices of projects, so she can choose her favorite.
- C. Staying away from the client during the session to encourage free expression.
- D. Structuring the activity to facilitate completion of one specific task.
Correct Answer: D
Rationale: Structuring the activity ensures success for a lethargic client, supporting engagement and achievement.
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.
During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse?
- A. Do you think you could sit still for a few minutes so we can talk?
- B. How are you ever going to get any rest if you keep that music on?
- C. Let's go to the conference room and talk for a while.
- D. Turn the radio down so we can hear ourselves talk.
Correct Answer: C
Rationale: Redirecting to a quieter environment reduces stimuli, promoting calmness and aiding rest.
Which individual is at highest risk for committing suicide?
- A. A 71-year-old male, alcohol user, independent minded
- B. A 16-year-old female, diabetic, two best friends
- C. A 47-year-old male, schizophrenic, unemployed
- D. A 57-year-old female, depression, active in church
Correct Answer: A
Rationale: Older men, especially with alcohol use and independence, are at higher suicide risk due to demographic and behavioral factors.
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.