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A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
- A. Secure the client’s valuable possessions
- B. Limit loud noises in the client’s environment
- C. Encourage the client to participate in structured solitary activities
- D. Provide high calorie snacks to the client
Correct Answer: D
Rationale: The correct answer is D: Provide high calorie snacks to the client. The priority intervention in this scenario is to address the client's lack of sleep and increased energy levels due to mania. Providing high-calorie snacks can help stabilize blood sugar levels and provide sustained energy, potentially aiding in promoting sleep. The other choices are incorrect because securing valuable possessions, limiting loud noises, and encouraging solitary activities do not directly address the immediate need to manage the client's symptoms related to lack of sleep and euphoria.
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A nurse is caring for a client in the emergency department who states she was beaten and sexually assaulted by her partner. After a rapid assessment, which of the following actions should the nurse plan to take next?
- A. Conduct a pregnancy test
- B. Request mental health consultation for the client
- C. Provide a trained advocate to stay with the client
- D. Offer prophylactic medication to prevent STI’s
- E. A client who describes having persistent feelings of anger about the hurricane.
Correct Answer: A
Rationale: The correct answer is A: Conduct a pregnancy test. This action is important to assess the client's risk of pregnancy resulting from the sexual assault. Pregnancy testing is crucial for timely decision-making regarding emergency contraception. This step is a priority in the care of a sexual assault survivor. It ensures appropriate medical intervention and support for the client's physical and emotional well-being.
Summary of other choices:
B: Requesting mental health consultation is important but not the immediate next step.
C: Providing a trained advocate is valuable for support but does not address the urgent medical needs of the client.
D: Offering prophylactic medication for STIs is important but not the immediate next step before assessing pregnancy risk.
E: This choice is unrelated to the situation described and should not be considered in this context.
A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?
- A. Schizoid personality disorder
- B. Alcohol intoxication
- C. Dysthymic disorder
- D. Long-term isolation
Correct Answer: B
Rationale: The correct answer is B: Alcohol intoxication. Alcohol intoxication can impair judgment, lower inhibitions, and increase aggression, leading to a higher risk of violent behavior. Schizoid personality disorder (A) is characterized by social detachment, not necessarily violence. Dysthymic disorder (C) involves chronic low mood but not a direct risk for violent behavior. Long-term isolation (D) may contribute to mental health issues but does not directly indicate violent behavior.
A nurse is caring for a client who has posttraumatic stress disorder related to military service. Which of the following actions should the nurse take?
- A. Encourage the client to suppress feelings of trauma
- B. Assign the same staff to care for the client each day
- C. Address the client in an authoritative manner
- D. Limit the amount of time spent with the client
Correct Answer: B
Rationale: The correct answer is B: Assign the same staff to care for the client each day. Consistency in care providers helps establish trust and a sense of safety for clients with PTSD. This familiarity can reduce anxiety and improve therapeutic rapport. Encouraging the client to suppress feelings of trauma (A) can be harmful as it may worsen symptoms. Addressing the client in an authoritative manner (C) can trigger feelings of threat. Limiting time spent with the client (D) can hinder the development of a therapeutic relationship.
A nurse in a mental health facility is assessing a client who has schizophrenia. The nurse should document which of the following as a positive symptom?
- A. Social withdrawal
- B. Flat affect
- C. Delusions
- D. Lack of motivation
Correct Answer: C
Rationale: The correct answer is C: Delusions. Positive symptoms are behaviors or experiences that are added to a person's personality, such as hallucinations or delusions. Delusions are false beliefs that are not based on reality. In the context of schizophrenia, delusions are considered positive symptoms because they represent an addition to a person's usual behavior or mental state. Social withdrawal (A), flat affect (B), and lack of motivation (D) are considered negative symptoms of schizophrenia, as they involve a decrease or absence of normal behaviors or emotions. Therefore, the nurse should document delusions as a positive symptom in the assessment of the client with schizophrenia.
A nurse in a mental facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide?
- A. The client is married
- B. The client is female
- C. The client is 50 years of age
- D. The client has diabetes mellitus
Correct Answer: C
Rationale: The correct answer is C: The client is 50 years of age. The SAD PERSONS scale includes age as a risk factor for suicide. As individuals get older, they may face more challenges such as chronic health conditions, loss of loved ones, or financial difficulties, which can increase suicidal ideation. This age group is considered at higher risk for suicide compared to younger individuals. Choices A, B, and D do not directly relate to suicide risk factors according to the scale. Being married (A) can sometimes be a protective factor, being female (B) is not a specific risk factor, and having diabetes mellitus (D) is a medical condition that is not directly associated with suicide risk based on the scale.