Nokea
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.
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A client asks the nurse why he has to go to therapy and cannot just take his prescribed antidepressant medication. Which would be the most therapeutic nursing intervention?
- A. Stating, 'The effects of medications will not last forever. You will need to eventually learn to function without them.'
- B. Stating, 'Medications help your brain function better, but the therapy helps you achieve lasting behavior change.'
- C. Stating, 'Both are recommended. Since your insurance covers both, that is the best plan for you.'
- D. Asking, 'Do you have reservations about going to therapy?'
Correct Answer: B
Rationale: Therapy complements medication by fostering lasting behavioral changes, addressing underlying issues.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority?
- A. Hopelessness related to recent divorce.
- B. Ineffective coping related to inadequate stress management.
- C. Spiritual distress related to conflicting thoughts about suicide and sin.
- D. Risk for suicide related to a highly lethal plan.
Correct Answer: D
Rationale: The risk for suicide with a lethal plan is the highest priority, as safety is paramount in this situation.
During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse?
- A. Do you think you could sit still for a few minutes so we can talk?
- B. How are you ever going to get any rest if you keep that music on?
- C. Let's go to the conference room and talk for a while.
- D. Turn the radio down so we can hear ourselves talk.
Correct Answer: C
Rationale: Redirecting to a quieter environment reduces stimuli, promoting calmness and aiding rest.
Which individual is at highest risk for committing suicide?
- A. A 71-year-old male, alcohol user, independent minded
- B. A 16-year-old female, diabetic, two best friends
- C. A 47-year-old male, schizophrenic, unemployed
- D. A 57-year-old female, depression, active in church
Correct Answer: A
Rationale: Older men, especially with alcohol use and independence, are at higher suicide risk due to demographic and behavioral factors.
A client who is depressed begins to cry and states, 'I'm just really sick of feeling this way. Nothing ever seems to go right in my life.' Which would be the most appropriate response by the nurse?
- A. Don't cry. Try to look at the positive side of things.
- B. You are feeling really sad right now. It's a hard time.
- C. Hang in there. Your medication will start helping in a few days.
- D. Nothing ever goes right?
Correct Answer: B
Rationale: Acknowledging the client's sadness validates their feelings, fostering a therapeutic connection without dismissing emotions.