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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Regression involves reverting to earlier developmental behaviors in response to stress. While the client’s current behaviors may reflect regression, her inability to remember specific events points more directly to another mechanism.

B) Denial is the refusal to accept reality or facts. The client acknowledges that her mother ran her father off, so she is not completely denying her past; instead, she seems to lack memory about certain aspects, which suggests a different mechanism.

C) Projection involves attributing one’s own unacceptable feelings or thoughts to someone else. The client is not projecting her feelings onto others; she is reflecting on her own experiences, so this is not the most accurate descriptor.

D) Repression is the unconscious blocking of unacceptable thoughts or memories. The client’s statement about not remembering possible abuse suggests that she may have repressed those memories as a way to cope with the emotional pain associated with her past. This aligns well with the client’s history of chronic depression and suicidal behavior.

A. Show the client the unit. B. Offer medication to the client. C. Explain the nurse's role to the client D. Read to the client his rights.

Correct Answer is C

Explanation

A) Showing the client the unit can be helpful for orientation, but it may not address the client's immediate emotional state. Since the client is exhibiting paranoia and sitting quietly, they might not feel safe or ready to engage in a tour.

B) Offering medication to the client may be appropriate later, but it does not address the client's current need for safety and trust. If the client is feeling paranoid, they might be suspicious of medications offered right away.

C) Explaining the nurse's role to the client is the first and most important intervention. This helps to establish trust and reduce anxiety, as it clarifies the nurse's intentions and reassures the client that they are there to provide support. Building rapport is crucial in dealing with a client exhibiting paranoia.

D) Reading the client their rights is important but may feel overwhelming to a client who is already anxious or paranoid. It’s more effective to first build a connection and establish a sense of safety before discussing rights or other formalities.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is D

Explanation

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the nurse implement first?

Correct Answer is C

Explanation

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle collision and taken to the hospital. The employee states, 1 can't believe this. What should I do? Which response is best for the nurse to provide in this crisis?

The nurse is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?