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The nurse is preparing a plan of care for a client demonstrating mania. Which interventions should be included in the plan of care?
- A. Place the client in seclusion.
- B. Ignore any client complaints.
- C. Use a firm and calm approach.
- D. Use short and concise explanations and statements.
- E. Remain neutral and avoid power struggles and value judgments.
- F. Firmly redirect energy into more appropriate and constructive channels.
Correct Answer: C,D,E,F
Rationale: A client with mania will be extremely restless, disorganized, and chaotic. Grandiose plans are extremely out of touch with reality, and judgment is poor. Interventions for the client in acute mania include using a firm and calm approach to provide structure and control, using short and concise explanations or statements because of the client's short attention span, remaining neutral and avoiding power struggles and value judgments, being consistent in approach and expectations and having frequent staff meetings to plan consistent approaches and to set agreed-on limits to avoid manipulation by the client, hearing and acting on legitimate client complaints, and redirecting energy into more appropriate and constructive channels.
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A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: D
Rationale: Visual hallucinations indicate an alteration in brain function in the cerebrum. The occipital lobe is located in the back of the head and is primarily responsible for seeing and receiving information and is responsible for visual hallucinations. The temporal lobe lies beneath the skull on both sides of the brain and is primarily responsible for hearing and receiving information via the ears. Symptoms indicating an alteration of function in the temporal lobe include auditory hallucinations, sensory aphasia, alterations in memory, and altered emotional responses. The frontal lobe is located in the anterior or front area of the brain and is primarily responsible for motor functions, higher thought processes such as decision making, intellectual insight and judgment, and expression of emotion. Symptoms indicating an alteration of function in the frontal lobe include changes in affect, alteration in language production, alteration in motor function, impulsive behavior, and impaired decision making. The parietal lobe lies beneath the skull at the back and top of the head and is primarily responsible for association and sensory perception. Symptoms indicating an alteration of function in the parietal lobe include alterations in sensory perceptions, difficulty with time concepts and calculating numbers, alteration in personal hygiene, and poor attention span.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.
The nurse provides care for a client who exhibits the signs and symptoms of acute confusion and delirium. Which strategy is appropriate for the nurse to implement?
- A. Keep the room organized and clean.
- B. Maintain a high environmental noise level.
- C. Keep lights in the room dimmed during the day.
- D. Use restraints as needed for client safety.
Correct Answer: A
Rationale: Keeping the room organized and clean minimizes sensory overload and confusion, promoting a calming environment for a client with delirium. High noise, dim lights, or restraints can worsen agitation and are not appropriate unless safety is imminently threatened.
A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client?
- A. Assign the client a new task to master.
- B. Turn on the television to a musical program.
- C. Make the client aware that the behavior is undesirable.
- D. Talk about the family pictures on display in the client's room.
Correct Answer: D
Rationale: Providing familiar objects will decrease anxiety. Decreasing environmental stimuli also aids in reducing agitation for the head-injured client. Option 1 does not simplify the environment because a new task may be frustrating. Option 2 increases stimuli. In option 3 the nurse uses negative reinforcement to help the client adjust.
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond?
- A. Do you want me to call your daughter?'
- B. Can you tell me a little about what has you so upset?'
- C. Try not to be so upset. Psychological stress is bad for your heart.'
- D. I understand how you feel. I'd cry, too, if I had a major heart attack.'
Correct Answer: B
Rationale: Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization.