A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?

As soon as lunch is over, the client will calm down.

The client's behavior is not an imminent threat to anyone's physical safety.

Other clients need to be protected from the intrusive behavior.

The client needs food and fluids in any way possible.

Answer and Explanation

The Correct Answer is C

Bipolar disorder during a manic episode is characterized by psychomotor agitation, impulsivity, and a significant lack of inhibitory control. Patients often exhibit intrusive behaviors and poor social boundaries due to heightened energy levels and diminished judgment. Management requires the nurse to provide a safe, structured environment while minimizing environmental stimuli that exacerbate the patient's hyperexcitable state.

Rationale:

A. Assuming the client will calm down after lunch ignores the pathology of sustained mania. Manic episodes involve persistent elevations in mood and activity that do not dissipate simply with the conclusion of a meal. Relying on time alone without active intervention allows for continued escalation of inappropriate and disruptive social behaviors.

B. Although the behavior may not involve physical violence, it still constitutes a violation of personal boundaries. Waiting for an imminent threat of physical safety to occur before intervening is a reactive rather than a proactive safety approach. The nurse must manage the environment to prevent the situation from escalating into a conflict.

C. The nurse is responsible for maintaining the milieu integrity and protecting the rights of all clients. Intrusive behaviors can provoke agitation or aggression in other patients, potentially leading to a volatile environment. Setting firm, consistent limits on the manic client’s behavior is necessary to ensure a therapeutic and safe dining experience.

D. Although nutrition is a priority in mania due to high metabolic demands, obtaining it by taking from others is unacceptable. The nurse should provide the client with portable finger foods and high-calorie fluids that can be consumed while moving. This strategy meets nutritional needs without compromising the safety or dignity of other clients.

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Correct Answer is ["B","D","E"]

Explanation

Bereavement involves the complex biopsychosocial process of responding to loss, necessitating the reorganization of the survivor's internal and external worlds. The emotional dimension of grieving requires affective processing to achieve the integration of the loss into the individual's new reality. Successful resolution is marked by the ability to experience psychological homeostasis and find meaning while moving forward without the physical presence of the deceased.

Rationale:

A. Forgetting about the loss is not a healthy or expected outcome of grief resolution. Healthy grieving involves maintaining a continuing bond with the deceased while acknowledging the reality of the death. Attempting to forget suggests the use of maladaptive defense mechanisms, such as repression, rather than the successful integration of the experience.

B. Reestablishing identity and purpose indicates the survivor is successfully navigating the reconstruction phase. Grief often shatters a person's sense of self, especially if their identity was closely tied to the deceased. Developing a new sense of agency and direction is a vital sign of emotional healing and adaptation to the new life circumstances.

C. A survivor's life can never return to the exact same state as it was before the loss, as the death represents a permanent transition. The goal of grieving is not restoration of the past, but rather functional adaptation to a changed reality. Expecting a return to the status quo can lead to complicated grief and emotional stagnation.

D. Developing new ways of managing life and forming new relationships demonstrates behavioral flexibility. This indicates the survivor has reached a level of accommodation where they can invest emotional energy into new areas of life. It reflects a shift from being occupied with the loss to engaging in restorative activities and social connections.

E. Gaining independence and confidence signifies that the survivor is mastering the functional demands of their new environment. This often involves learning skills previously performed by the deceased, which fosters a sense of self-efficacy. Increased confidence is a strong indicator that the acute emotional distress of grief is diminishing and being replaced by resilience.

A. assess the appropriateness of the setting for implementing nursing skills. B. become aware of possible barriers to developing therapeutic relationships. C. assign the most compatible clients to the students. D. practice reflective communication skills in a role play situation.

Correct Answer is B

Explanation

In a forensic psychiatric setting, where clients are often hospitalized due to legal involvement or criminal offenses related to their mental illness, nursing students may encounter significant internal conflict. Discussing personal beliefs and fears is a critical exercise in self-awareness, ensuring that a student's preconceived notions do not impede the delivery of ethical and compassionate care.

Rationale:

A. The instructor has already determined that the setting is appropriate for learning before the rotation begins. Assessing the setting's utility is an administrative task rather than a reason for a personal debrief with students regarding their internal emotional states.

B. This is the primary objective. Personal biases, fears, or judgments regarding a client's past actions can lead to countertransference, where the nurse unknowingly projects their feelings onto the client. By identifying these beliefs early, students can work to mitigate them, ensuring they can build a therapeutic relationship based on the client's current needs rather than their legal history.

C. Assigning compatible clients based on a student's personal comfort level is not the goal of clinical education. Nursing students must learn to care for all clients regardless of their background. Adjusting assignments to avoid discomfort prevents the student from developing the professional objectivity required in nursing practice.

D. Reflective communication is a vital skill, but it is a tool used during the discussion, not the primary reason for it. The core purpose of the conversation is to clear the psychological path so that the student can engage with the forensic population without judgmental barriers.

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A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The bereaved client has worked through many processes of grief with the nurse. Which are eventual outcomes of the emotional dimension of grieving? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

When preparing for the first clinical experience with clients on a forensic unit at a psychiatric hospital, the nursing instructor discusses students' beliefs and fears surrounding forensic clients. The primary reason for discussing personal beliefs is to:

Correct Answer is B

Explanation

Which questions would help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia? Select all that apply.

The client tells the nurse, "I don't think you can help me. Every time I talk to you, I am reminded of my mother, and I hated her." The nurse should recognize this as:

The client suffers from bipolar disorder. The client is experiencing a downward spiral. For which drug should the nurse expect the client to require serum level monitoring?

A client diagnosed with a mild anxiety disorder has been referred to treatment in a community mental health center. Treatment most likely provided at the center includes?

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The client says to the nurse, "I really want to see my first grandchild born before I die. Is that too much to ask?" The nurse would recognize that the client is in which stage of grieving, according to Kubler-Ross?

Which nursing intervention constitutes false imprisonment?