Nokea
A 56-year-old woman hospitalized with bipolar disorder. While the patient is in the manic phase.
Nursing interventions should involve
- A. talking to the patient and reinforcing behaviors.
- B. distracting the patient and redirecting behaviors.
- C. limit-setting and isolating the patient.
- D. orienting to and reminding the patient of the rules of the hospital.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not be effective in changing behaviors, requires an attentive listener (2) correct-patient experiences hyperactivity, poor concentration, and distractibility, redirect into activity that promotes rest, nourishment, reduce stimuli (3) isolation not required, would increase anxiety and hostility (4) disorientation usually not seen, no memory disturbance
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The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states
- A. I will massage my legs three times a day.
- B. I will elevate the foot of my bed on blocks.
- C. I will take a brisk walk for 20 minutes each day.
- D. I will prop my feet up when I sit to watch TV.
Correct Answer: C
Rationale: Answer C is the 'odd answer' and correct. Walking improves circulation by developing muscles that support blood vessels. Massaging may dislodge clots, elevating the bed is not specific to circulation, and propping feet reduces venous pooling but is less effective than walking.
A client describing seeing snakes on the walls of his room in a psychiatric facility.
Based on this information, the nurse should identify a nursing diagnosis of
- A. sensory-perceptual alterations: visual.
- B. altered thought processes.
- C. ineffective individual coping.
- D. impaired social interaction.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data
An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
- A. a coping strategy.
- B. a defense mechanism.
- C. a way to not bother the nurse.
- D. regression.
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.
A psychiatric nurse is assigned to conduct an admission nursing history on a new client.
- A. What should the admission nursing history for a new psychiatric client include?
- B. The nurse’s opinion regarding the mental and emotional status of the client.
- C. Data addressing the client’s emotional state.
- D. Data that address a biopsychosocial approach, including a family system assessment.
- E. Specific data detailing the client’s mental status.
Correct Answer: C
Rationale: A comprehensive psychiatric nursing history should use a biopsychosocial approach, including physical, psychological, social, and family system assessments, to provide a holistic understanding of the client’s needs. Focusing only on emotional state or mental status is too narrow, and the nurse’s opinion lacks objectivity without assessment data.
A client with an acute attack of gout is started on colchicines (Colorys). She should be instructed to report which of the following symptoms?
- A. Diarrhea
- B. Headache
- C. Itching
- D. Fever
Correct Answer: A
Rationale: Colchicine commonly causes diarrhea, which should be reported to prevent dehydration or other complications.