Nokea
The wife of a client with bipolar disorder calls the nurse expressing distress about recent spending. The nurse's action would be considered
- A. inappropriate; the nurse should not give advice to the wife.
- B. inappropriate; the husband has the legal right to spend personal money.
- C. appropriate; the wife is responsible for the husband's actions since he has a mental illness.
- D. appropriate; the wife needs support in setting boundaries.
Correct Answer: D
Rationale: Supporting the wife in setting boundaries is appropriate, as it empowers her to manage the client's manic behavior.
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The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
- A. The client will avoid causing harm to others.
- B. The client will be free from stress.
- C. The client will independently carry out activities of daily living.
- D. The client will not experience agitation.
Correct Answer: C
Rationale: Independently performing activities of daily living is a realistic and appropriate outcome for a client with depression.
The nursing instructor is conducting a preconference with a group of nursing students on a psychiatric unit. Which statement made by a student reflects the greatest barrier to being able to provide professional care to the client who is suicidal?
- A. I just don't understand why anyone would want to kill themselves.
- B. I think suicide is wrong and selfish.
- C. I get frustrated when my client negates all the positives I try to point out.
- D. I can see how much my client is hurting inside.
Correct Answer: B
Rationale: Viewing suicide as wrong and selfish reflects a judgmental attitude, which can hinder empathetic and effective care.
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.
A client who is manic states, 'What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?' Which would be the most appropriate response by the nurse?
- A. Please slow down. I'm not sure what you need first.
- B. You will have to be quiet and have breakfast after the doctor comes.
- C. Are you hungry?
- D. Your thoughts seem to be racing this morning.
Correct Answer: A
Rationale: Asking the client to slow down facilitates communication without blaming, addressing their pressured speech.
A client who is depressed states, 'I think my family would be better off without me. They don't need to worry.' Which would be the most appropriate response by the nurse?
- A. Are you planning to commit suicide?
- B. What do you think they are worried about?
- C. You don't mean that. Your family loves you.
Correct Answer: A
Rationale: Directly asking about suicidal plans addresses potential ideation, ensuring safety and opening further assessment.