A nurse in an acute care mental health facility is sitting with a client who has schizophrenia.

The client whispers to the nurse, “I’m being kept in this prison against my will.

Please try to get me out.” Which of the following responses should the nurse make?

Choice A rationale:

Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.

Choice B rationale:

Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.

Choice D rationale:

Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.

Choice C rationale:

Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:

Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.

Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.

Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.

Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.

Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.

Choice A rationale:

Psychomotor retardation is a characteristic of depression, not hypomania. In fact, individuals with hypomania typically exhibit psychomotor agitation, which is characterized by increased energy and activity levels.

Psychomotor retardation often manifests as slowed movements, speech, and thought processes. It can significantly impact an individual's ability to perform daily tasks and engage in social interactions.

While psychomotor retardation can occur in various mental health conditions, it is not typically associated with hypomania.

Choice B rationale:

Decreased self-esteem is also a characteristic of depression, not hypomania. Individuals with hypomania typically experience inflated self-esteem and grandiosity.

They may overestimate their abilities, make unrealistic plans, or engage in risky behaviors. This inflated sense of self-worth is often a hallmark feature of hypomania and can contribute to impaired judgment and decision-making.

Choice C rationale:

Euphoria is a hallmark symptom of hypomania. It is characterized by an elevated, expansive, or irritable mood that is persistent and noticeable to others.

Individuals with euphoria often feel excessively happy, cheerful, or optimistic. They may have increased energy, decreased need for sleep, and a heightened sense of well-being.

They may also be more talkative, outgoing, and engage in pleasurable activities more often.

This elevated mood is a core feature of hypomania and is often accompanied by other characteristic symptoms, such as increased activity levels, racing thoughts, and impulsivity.

Choice D rationale:

Hallucinations are not a typical feature of hypomania. They are more commonly associated with psychotic disorders, such as schizophrenia.

Hallucinations involve perceiving things that are not real, such as hearing voices or seeing things that are not there.

While hallucinations can occur in some individuals with hypomania, they are not a defining feature of the condition