Nokea
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
- A. Place the client in seclusion when he exhibits signs of anxiety.
- B. Encourage the client to spend time in the dayroom.
- C. Withdraw the client's TV privileges if he does not attend group therapy.
- D. Encourage the client to take frequent rest periods.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to take frequent rest periods. During manic episodes in bipolar disorder, individuals often experience decreased need for sleep and increased energy levels. Encouraging the client to take rest periods can help prevent exhaustion and promote relaxation, which may help in managing manic symptoms. Placing the client in seclusion when anxious (choice A) can exacerbate feelings of isolation and distress. Encouraging the client to spend time in the dayroom (choice B) may increase stimulation, which can worsen manic symptoms. Withdrawing TV privileges (choice C) for not attending group therapy may not directly address the manic symptoms. Thus, choice D is the most appropriate intervention for managing mania in this client.
You may also like to solve these questions
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
- A. We should discuss resources to implement in your daily life.
- B. Let me show you simple relaxation exercises to manage stress.
- C. We should establish our roles in the initial session.
- D. Let's talk about how you can change your response to stress.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: During the orientation phase of the therapeutic relationship, establishing roles is crucial for setting boundaries and clarifying expectations. This helps build trust and create a safe environment for the client to open up. Discussing resources (A) and relaxation exercises (B) would be more appropriate in later phases once the therapeutic relationship is established. Talking about changing responses to stress (D) may be premature at this stage.
A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?
- A. Inability to carry out a simple task
- B. Client reports auditory hallucinations
- C. Moves quickly from one idea to the next
- D. Client expresses illusions of grandeur
Correct Answer: A
Rationale: The correct answer is A: Inability to carry out a simple task. During a depressive episode in bipolar disorder, individuals often experience cognitive impairment, including difficulty concentrating and making decisions. This can lead to an inability to carry out simple tasks. Choices B, C, and D are more indicative of symptoms seen in manic episodes, such as auditory hallucinations (B), racing thoughts (C), and grandiosity (D). By understanding the characteristic symptoms of bipolar disorder episodes, the nurse can appropriately assess and provide interventions for the client.
A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
- A. A client who has narcissistic personality disorder and is mocking others during group therapy
- B. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
- C. A client who has depressive disorder and requires assistance with ADLs
- D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client taking clozapine first due to the potential side effect of agranulocytosis, which can manifest as a sore throat. This is a serious adverse effect that requires immediate attention to prevent complications. The other clients do not present with urgent or life-threatening issues. A: Narcissistic behavior is disruptive but not a medical emergency. B: Upset about a routine change is distressing but does not pose a physical health risk. C: Assistance with ADLs is important but not immediately life-threatening. Therefore, prioritizing the client on clozapine with a sore throat is crucial to ensure timely intervention and prevent serious complications.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.
A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following medications should the nurse expect to administer?
- A. Methadone
- B. Disulfiram
- C. Lorazepam
- D. Bupropion
Correct Answer: C
Rationale: The correct answer is C: Lorazepam. Lorazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing anxiety, insomnia, and seizures. It helps stabilize the client during detoxification. Methadone (A) is used for opioid withdrawal, Disulfiram (B) is a deterrent for alcohol consumption, and Bupropion (D) is used for smoking cessation.