A female client who is a retired school teacher is admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of this client's behavior by the nurse is likely to be most accurate?

Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety.

Should be encouraged as representative of the client's non-destructive method of fear expression.

Unacceptable, and limits should be set to encourage the client to maintain her independence.

Should be accepted by staff as the first step the client must experience in the grieving process.

Answer and Explanation

The Correct Answer is A

A.   This behavior can be seen as a regression aimed at reducing anxiety during a stressful time, which is a relatively common psychological response to stress or trauma.
B.   While it may be a way for the client to cope, encouraging dependency might not necessarily be the best approach to fostering independence.
C.   While independence is important, setting rigid limits might not address the underlying emotional needs during a period of distress.
D.   Acknowledging and understanding the client's behavior as a coping mechanism within the grieving process can help the staff provide appropriate support and care.

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Correct Answer is A

Explanation

A. Exploring changes in life after the loss can help the nurse understand the client's current situation and provide a basis for further interventions.
B. Suggesting psychiatric consultation might be necessary but might not be the immediate first step without assessing the client's current needs.
C. Offering a referral to pastoral counseling might be helpful, but understanding the client's current state is important before making specific referrals.
D. Encouraging attendance at a local support group could be beneficial but might not be the immediate priority without understanding the client's current emotional state.

A. Invite for a walk when the client's energy is high. B. Engage the client in competitive activities. C. Assign the client to a single room. D. Provide television programs with suspense to keep attention engaged. E. Give concise and firm directions for hygiene and dressing.

Correct Answer is ["A","C","E"]

Explanation

A. Inviting for a walk when the client's energy is high can help channel excess energy and reduce restlessness.
B. Engaging the client in competitive activities might escalate the situation and isn't suitable for managing hyperactivity in bipolar disorder.
C. Assigning the client to a single room can reduce external stimuli and potentially decrease overstimulation that might contribute to the behavior.
D. Providing television programs with suspense might not effectively engage the client or address their needs.
E. Giving concise and firm directions for hygiene and dressing can help provide structure and guidance during times of excessive energy or impulsivity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Correct Answer is A

Explanation

The nurse is planning the care for a client who is hospitalized with bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

The nurse is assessing a client who reports using cocaine several times in the past week.Which observations should the nurse expect on assessment?