A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

Set limits on aggressive and intimidating behaviors

Offer to hold a group about healthy coping skills

Administer the client’s PRN medications

Insist the client take a “time-out” in their room

Answer and Explanation

The Correct Answer is A

Choice A reason: Setting limits on aggressive behavior during mania ensures safety by addressing the immediate threat. Mania involves elevated mood and impulsivity, which can lead to harmful actions. Clear boundaries reduce escalation, protect others, and help de-escalate the client’s heightened state without immediate medication or isolation.

Choice B reason: Offering a group on coping skills is inappropriate during acute mania with threatening behavior, as the client’s impulsivity and agitation impair their ability to engage in group therapy. Safety and de-escalation are priorities before addressing long-term coping strategies.

Choice C reason: Administering PRN medications, such as antipsychotics or benzodiazepines, may help calm mania but is not the initial action. Setting limits addresses immediate safety concerns first, allowing for safer medication administration if needed, as medications take time to act.

Choice D reason: Insisting on a “time-out” may escalate agitation in a manic client, as isolation can increase feelings of persecution or agitation. This approach is less effective than setting clear, calm limits to de-escalate threatening behavior and ensure unit safety.

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Correct Answer is D

Explanation

Choice A reason: Resuming vigorous activity like tennis one week post-pacemaker insertion risks lead dislodgement, as the device requires time to stabilize. Arm movements in tennis, especially overhead swings, can disrupt the pacemaker leads, making this advice unsafe and inappropriate.

Choice B reason: Suggesting hockey or skating as alternatives is incorrect, as these activities also involve significant physical exertion and risk of trauma to the pacemaker site. Additionally, delaying until fall is arbitrary, and these sports do not reduce the risk of lead dislodgement compared to tennis.

Choice C reason: Substituting tennis with basketball or football is inappropriate, as these contact sports pose a higher risk of trauma to the pacemaker site, potentially causing device malfunction or lead dislodgement. These activities are not safer alternatives and could exacerbate complications.

Choice D reason: Restricting arm movement above the head for two weeks post-pacemaker insertion prevents lead dislodgement, as the leads need time to anchor in the heart tissue. Tennis involves vigorous arm motions, so canceling the tournament is necessary to ensure device stability and client safety.

A. Assess for past history of suicide attempts B. Notify all members of the treatment team and place the client on suicide precautions C. Identify coping mechanisms D. Determine whether the client has a specific plan to die by suicide

Correct Answer is B

Explanation

Choice A reason: Assessing past suicide attempts provides risk context but is not the immediate priority. Current suicidal ideation requires urgent action to ensure safety, as past history does not address the acute risk of self-harm, making this secondary to implementing protective measures.

Choice B reason: Notifying the treatment team and initiating suicide precautions is the priority to ensure immediate safety. Suicidal ideation indicates a high risk of self-harm, requiring team coordination, constant observation, and environmental safety measures to prevent harm and ensure timely intervention.

Choice C reason: Identifying coping mechanisms is part of long-term suicide prevention but is not the priority during active suicidal ideation. Immediate safety measures, such as precautions and team notification, are critical to prevent harm before addressing coping strategies in therapy.

Choice D reason: Determining a specific suicide plan is important for risk assessment but is secondary to initiating immediate safety measures. Suicide precautions and team notification ensure the client’s safety first, allowing for subsequent detailed evaluation of the ideation’s specificity and intent.

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A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in one week. What teaching should the nurse provide to the client related to this activity?

Correct Answer is D

Explanation

A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Correct Answer is B

Explanation

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