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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.
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Which client is at highest risk for carrying out a suicide plan?
- A. A client who plans to take a bottle of sleeping pills.
- B. A client who says, 'My life is over.'
- C. A client who has a private gun collection.
- D. A client who says, 'I'm going to jump off the next bridge I see.'
Correct Answer: C
Rationale: Access to a lethal means like a gun collection significantly increases the likelihood of completing a suicide plan.
At 1 AM, the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. What would be the nurse's most therapeutic response?
- A. Go to the day room and wait while I call your psychiatrist.
- B. Don't be unreasonable. I can't call the psychiatrist at this time of night.
- C. I can't call the psychiatrist now, but you and I can talk about your request for a pass.
- D. You must really be upset to want a pass immediately; I'll give you some medication.
Correct Answer: C
Rationale: This response sets limits on an unreasonable demand while opening a dialogue to address the client's needs.
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.
Which statements about the etiology of bipolar disorder do most psychoanalytical theories subscribe to? Select all that apply.
- A. Norepinephrine levels may be increased in mania.
- B. Manic episodes are a defense against underlying depression.
- C. Acetylcholine seems to be implicated in mania.
- D. The id takes over the ego and acts as an undisciplined hedonistic being (child).
Correct Answer: B,D
Rationale: Psychoanalytical theories view mania as a defense against depression, with the id overriding the ego, acting impulsively.
A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?
- A. Decrease the client's environmental stimuli.
- B. Give the client feedback about his behavior.
- C. Introduce the client to other staff on the unit.
- D. Tell the client about hospital rules and policies.
Correct Answer: A
Rationale: Reducing environmental stimuli is the priority to help calm an agitated client with bipolar disorder.