A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

"I understand that you're angry and unhappy. Let's explore ways in which you overreact."

"I hear your frustration about losing control. Tell me how this affects your daily life."

"Knowing the cause of your symptoms will make them easier to handle."

"Do all that you can to learn all that you can while you are here. You can get better."

Answer and Explanation

The Correct Answer is B

A.   This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B.   This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C.   While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D.   While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

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Correct Answer is A

Explanation

A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.

B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.

A. Reinforce the need for the adolescent to attend group therapy sessions. B. Tell the mother to describe her feelings of helplessness to her child. C. Advise the mother to call the police if violent behavior occurs again. D. Refer the mother for psychiatric evaluation for anxiety and depression.

Correct Answer is C

Explanation

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

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A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?