A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

Move to a quiet area and provide peanut butter with crackers.

Encourage the spouse to eat lunch with the client.

Walk with the client to the cafeteria and stay while client eats.

Request a full lunch tray from the dietary department.

Answer and Explanation

The Correct Answer is C

A) Moving to a quiet area and providing peanut butter with crackers may help address the client’s nutritional needs, but it may not adequately address the client’s agitation and pacing. The immediate priority is to stabilize the client’s behavior before focusing on nutrition.

B) Encouraging the spouse to eat lunch with the client may create an opportunity for social interaction, but it might not be effective in calming the client’s agitation. If the client is already highly agitated, the spouse's presence alone may not help diffuse the situation.

C) Walking with the client to the cafeteria and staying while the client eats is the best intervention at this time. This approach allows the nurse to provide a calming presence and guidance while encouraging the client to eat. It also helps redirect the client's energy and agitation into a structured activity, promoting both physical movement and nutrition, which is crucial after several days without food.

D) Requesting a full lunch tray from the dietary department could provide a more substantial meal; however, it might not address the immediate need for calming the client. If the client remains agitated and loud, it may be challenging to ensure that they can eat peacefully, making this intervention less effective than accompanying the client directly to eat.

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Correct Answer is D

Explanation

A) Disrupting group activities indicates behavioral issues, but it alone does not necessarily warrant constant observation. While disruptive behavior can be concerning, it may not pose an immediate risk to the client or others.

B) Talking with nonsensical words suggests disorganized thinking or possible psychosis, which is important to note. However, this behavior does not by itself indicate that the client is in immediate danger or that they require constant observation.

C) Refusing antipsychotic medications is a significant factor, particularly in managing the client's mental health. However, refusal of medication does not automatically necessitate constant observation unless it leads to behaviors that put the client or others at risk.

D) Wandering into clients' rooms is the most concerning behavior in this context. This action can pose a risk to both the individual and other clients, potentially leading to boundary violations or safety issues. Constant observation is warranted to ensure the safety of all clients and to manage the individual's behavior effectively.

A. Allow the client time alone to sort out any feelings. B. Avoid discussing subjects that upset the client. C. Encourage activities that allow the client to exert control over the client's environment. D. Encourage the client to interact with persons who are recovering from depression.

Correct Answer is C

Explanation

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

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A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

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