A home health nurse arrives at the home of a client who is in the manic phase of bipolar disorder.
The client is shouting at their family and is intermittently uncooperative.
Which of the following is the priority action by the nurse?
Discuss the client's problems and support systems.
Ensure the safety of the client and others.
Assist the client with implementing coping skills.
Assist the client to a quiet area with minimal environmental stimuli.
The Correct Answer is B
Choice A rationale
Discussing problems and support systems is an important long-term goal but is not the immediate priority during an acute manic episode with aggressive behavior. An agitated client in a manic state is unlikely to be receptive to a rational discussion. The immediate concern is to de-escalate the situation and prevent harm.
Choice B rationale
The safety of the client and others is always the priority in a volatile situation. A client in the manic phase who is shouting and uncooperative poses a risk for harm to themselves and those around them. The nurse must first ensure a safe environment before attempting any other interventions.
Choice C rationale
While helping the client implement coping skills is a good intervention, it is not the priority during an acute crisis. The client’s agitation makes them unable to utilize coping skills effectively. The nurse must first ensure safety and de-escalate the situation before attempting to teach or reinforce new behaviors.
Choice D rationale
Moving the client to a quiet area is a component of de-escalation and creating a safer environment, but the ultimate priority action is the broader concept of ensuring safety, which includes this action along with other measures like removing potential weapons and calling for help if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
This instruction describes part of a different vision screening test, likely the alternate cover test or a version of it, which assesses for phorias (latent strabismus) by observing eye movement after the cover is removed. The cover test assesses tropias (manifest strabismus) by observing the uncovered eye. The instruction is not suitable for the standard cover test, which focuses on observing the covered eye as it is uncovered.
Choice B rationale
This describes the Hirschberg test, also known as the corneal light reflex test, which is used to screen for strabismus by observing the location of the light reflection on the corneas. This is a quick screening tool, but it does not provide the detailed assessment of eye movement and alignment that the cover test provides. Therefore, the instruction is inaccurate for a cover test procedure.
Choice C rationale
The cover test is a diagnostic procedure used to detect a tropia or misalignment of the eyes. The client is instructed to fixate on a target, typically an object or finger, while one eye is occluded. The nurse observes the uncovered eye for any movement, which would indicate a manifest deviation. Then, the nurse uncovers the eye and observes for any refixation movement, indicating the presence of a tropia.
Choice D rationale
This instruction describes a component of the Snellen eye chart test, which is used to measure visual acuity, not ocular alignment. Visual acuity testing assesses the sharpness of vision by having the client read letters of various sizes from a standardized distance. This is a separate and distinct assessment from the cover test, which specifically evaluates how the eyes work together.
Correct Answer is B
Explanation
Choice A rationale
The nurse’s role is to act as a facilitator and advocate for the client's autonomy, not to give advice. Advising the client on specific decisions could be seen as coercion and would violate the principle of self-determination. The client should make decisions based on their own values and wishes.
Choice B rationale
A durable medical power of attorney (DPOA) is a person designated to make healthcare decisions for the client if they become unable to do so themselves. It's crucial for the DPOA to be aware of the client's advance directives to ensure their decisions align with the client’s wishes, thereby honoring their autonomy and intent.
Choice C rationale
An advance directive is a legal document and must be included in the client's medical record. This ensures that the healthcare team is aware of the client's wishes regarding their care, and is a legal and ethical requirement. The document needs to be easily accessible to all healthcare providers involved in the client’s care.
Choice D rationale
Advance directives are broad legal documents that can cover various aspects of care, not just a do-not-resuscitate (DNR) order. They can include a living will, which specifies preferences for life-sustaining treatments, as well as the appointment of a healthcare proxy or DPOA to make decisions on their behalf.
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