A newly admitted client asks. "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing response?

"Group therapy is an economical way of providing therapy to many clients concurrently."

"Group therapy is optional. You can go if you find the topic helpful and interesting."

Group therapy is mandatory. All clients must attend."

"The purpose of group therapy is to learn and practice new coping skills.

Answer and Explanation

The Correct Answer is B

A. "Group therapy is an economical way of providing therapy to many clients concurrently.": While this statement may be true, it does not directly address the client's concerns or provide information about the voluntary nature of group participation.

B. "Group therapy is optional. You can go if you find the topic helpful and interesting.": This is the correct answer. Acknowledging the client's autonomy and providing information about the voluntary aspect of group therapy respects the client's preferences and promotes a collaborative therapeutic relationship.

C. "Group therapy is mandatory. All clients must attend.": This statement is more authoritarian and does not take into account the individual needs and preferences of the client. It is important to involve clients in decisions about their treatment whenever possible.

D. "The purpose of group therapy is to learn and practice new coping skills.": While this statement provides information about the purpose of group therapy, it does not directly address the client's question about the optional nature of attendance.

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Correct Answer is D

Explanation

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

A. Altered thought process related to hallucinations. B. Risk for violence related to poor impulse control and judgement. C. Altered thought process related to poor judgement. D. Social isolation related to mania.

Correct Answer is B

Explanation

A. Altered thought process related to hallucinations: While altered thought processes are common in manic episodes, hallucinations are not typically associated with mania in Bipolar I disorder. Hallucinations are more commonly seen in psychotic disorders.

B. Risk for violence related to poor impulse control and judgment: This is the correct priority diagnosis. During a manic episode, individuals may have impaired impulse control and poor judgment, increasing the risk of impulsive and potentially violent behaviors. Ensuring the safety of the client and others is the priority.

C. Altered thought process related to poor judgment: While altered thought processes and poor judgment are characteristic of mania, the specific concern in this scenario is the potential for violence. The risk for violence takes precedence as a priority nursing diagnosis.

D. Social isolation related to mania: Social isolation may be a concern, but the immediate priority is addressing the risk for violence, as it poses a more significant threat to the client and others during a manic episode.

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A newly admitted client asks. "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Correct Answer is D

Explanation

A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?

Correct Answer is B

Explanation

A nurse is caring for a client who has a mental illness and is without housing. The nurse should identify that which of the following interprofessional team members can help the client find housing?

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

Which hallucination necessitates the nurse to implement safety measures? The patient says.

A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?

depressed client states. I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again. Which nursing response is appropriate?

Thorazine 150mg PO was order for a client. Thorazine is available in 50mg tablets. How many tablets will you administer?

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation?