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A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
- A. A private room in a quiet location on the unit
- B. A semiprivate room with a roommate who has similar symptoms
- C. A private room close to the nursing station
- D. A seclusion room until the client's activity level becomes more subdued
Correct Answer: C
Rationale: The correct answer is C: A private room close to the nursing station. This choice ensures the client's safety and allows for close monitoring by the nursing staff due to the increased risk of impulsive behaviors during the manic phase. A private room helps minimize distractions and stimuli that can exacerbate manic symptoms, while proximity to the nursing station enables quick intervention if needed.
Incorrect choices:
A: A private room in a quiet location on the unit - While privacy is important, a quiet location may not provide adequate supervision and support for a client in the manic phase.
B: A semiprivate room with a roommate who has similar symptoms - Sharing a room with someone exhibiting similar symptoms may lead to escalation of behaviors and lack of supervision.
D: A seclusion room until the client's activity level becomes more subdued - Seclusion should only be used as a last resort for safety concerns and is not appropriate for managing manic symptoms.
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A nurse is conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?
- A. Magical thinking
- B. Delusions of grandeur
- C. Ideas of reference
- D. Looseness of association
Correct Answer: C
Rationale: The correct answer is C: Ideas of reference. This behavior is indicative of ideas of reference, a common symptom of schizophrenia where individuals believe that neutral events or comments are directed at them personally. In this case, the client's perception of laughter at a joke led them to believe it was directed towards them, triggering a paranoid reaction. This is different from magical thinking (A) which involves belief in unrealistic events, delusions of grandeur (B) which involves exaggerated beliefs in one's importance, and looseness of association (D) which is characterized by disconnected thoughts. The other choices are not relevant to the scenario provided.
A nurse is caring for an adolescent client who has conduct disorder. The client reports that she has received five speeding tickets in the past 6 months. Which of the following interventions should the nurse take?
- A. Make a contract with the client not to drive over the speed limit.
- B. Call the local police and alert them to the client's car license plate number and the make and model of her car.
- C. Ask the client to "hand over the keys" to you and tell her that now she must use a cab or other public transportation until your next session.
- D. Inform the client that she cannot drink and drive.
Correct Answer: A
Rationale: The correct answer is A: Make a contract with the client not to drive over the speed limit. This intervention is appropriate as it establishes clear boundaries and expectations for the client's behavior, addressing the issue of multiple speeding tickets. By creating a contract, the nurse can work with the client to set specific goals and consequences for adhering to the speed limit. This method promotes accountability and helps the client understand the importance of safe driving practices.
Other choices are incorrect:
B: Calling the local police would breach confidentiality and trust, which is not ethical.
C: Taking away the client's keys may be seen as punitive and could lead to resistance or defiance.
D: While important, the issue of drinking and driving is not directly related to the client's speeding tickets.
A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?
- A. "I plan to sit on a park bench for a few minutes each day."
- B. "I can try participating in group therapy every week."
- C. "I will join a book club in my neighborhood."
- D. "I should avoid entering elevators and other closed spaces."
Correct Answer: A
Rationale: The correct answer is A: "I plan to sit on a park bench for a few minutes each day." This statement indicates the client's understanding of gradual exposure therapy, a common treatment for agoraphobia. Exposure to feared situations in a controlled manner helps desensitize the client to their anxiety triggers. Sitting on a park bench signifies a small step towards facing the fear of open spaces. Choices B, C, and D do not directly address the core issue of agoraphobia or the specific treatment approach. Group therapy and joining a book club may be beneficial but do not target the fear of open spaces. Avoiding elevators and closed spaces is a safety behavior that reinforces the fear and hinders recovery.
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
- A. Agranulocytosis
- B. Akathisia
- C. Tardive dyskinesia
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). The client's symptoms of high fever, hypertension, and muscle rigidity are classic signs of NMS, a rare but life-threatening adverse effect of antipsychotic medications like haloperidol. NMS is a medical emergency that can lead to severe complications such as rhabdomyolysis, renal failure, and even death if not promptly recognized and treated. Agranulocytosis (A) is a potential side effect of some antipsychotic medications but typically presents with symptoms like fever and sore throat due to low white blood cell count. Akathisia (B) is a movement disorder characterized by restlessness and a compelling need to move, which is not consistent with the client's symptoms. Tardive dyskinesia (C) is a late-onset movement disorder associated with long-term antipsychotic use and typically presents with involuntary movements of the face and extremities, not fever
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?
- A. "I will assist you in getting out of bed and getting dressed."
- B. "You can remain in bed until you feel well enough to join the group."
- C. "The unit rules state that you may not remain in bed."
- D. "If you don’t participate in your care, you will not get better."
Correct Answer: A
Rationale: Rationale: Choice A is correct because it demonstrates empathy, support, and encouragement. By offering assistance in getting out of bed and getting dressed, the nurse is promoting the client's self-care and well-being. This statement acknowledges the client's feelings while also providing the necessary support to engage in daily activities.
Incorrect Choices:
B: This choice enables the client's avoidance behavior and does not promote active participation in therapy or self-care.
C: This statement is authoritarian and does not address the client's emotional state or needs, which can worsen the client's depression.
D: This statement is negative and may induce guilt or shame in the client, which is counterproductive in supporting their mental health recovery.