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) Telling the client that it is important to respect others' belongings may be a valid point, but it does not address the immediate behavior and does not provide a practical solution. Simply stating this may not help the client understand the consequences of her actions or modify her behavior.

B) Taking away privileges until the behavior is extinguished can lead to feelings of punishment and may not be effective in changing the behavior. It is essential to approach the situation with understanding rather than punitive measures.

C) Doing nothing is not an appropriate response. While the behavior may not be physically harmful, it can disrupt the community and the therapeutic environment of the facility. It is important to address the behavior proactively.

D) Removing the client from these areas when she is agitated is the most appropriate action. This intervention helps to prevent the behavior from occurring and allows the nurse to manage the client’s agitation in a constructive way. It provides an opportunity to redirect her focus and reduce her agitation, promoting a safer environment for all clients.

A. Why do you think you have a hostile work environment? B. How have you responded to those in your work environment about these events? C. Have you considered resigning from you position? D. Have the feelings associated with these events brought you to the clinic?

Correct Answer is B

Explanation

A) Why do you think you have a hostile work environment?:Asking this question might come across as dismissive or challenging the client’s perception of their experience. It is important to validate the client’s feelings and experiences rather than questioning their interpretation of the situation.

B) How have you responded to those in your work environment about these events?:This response encourages the client to reflect on their actions and coping strategies. It shows empathy and interest in understanding the client’s perspective and experiences, which can help build rapport and provide valuable insights for further discussion and support.

C) Have you considered resigning from your position?:Suggesting resignation might not be appropriate at this stage, as it could increase the client’s stress and anxiety. It is important to explore the client’s feelings and experiences first before discussing potential solutions or changes in their employment situation.

D) Have the feelings associated with these events brought you to the clinic?:While this question acknowledges the client’s feelings, it may not provide an opportunity for the client to elaborate on their experiences and coping strategies. It is important to focus on understanding the client’s actions and responses to the events they described.

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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

An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's understanding of the discharge teaching, which statement made by the client shows awareness of the most important self-care goal?

During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

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