A nurse is assisting in the care of a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take to promote a therapeutic environment?

Allow the client to choose activities for the day.

Redirect client behavior by initiating physical exercise.

Encourage the client to spend time with others

Be specific when explaining care to the client.

Answer and Explanation

The Correct Answer is D

A.   Allowing the client to choose activities may lead to decision fatigue or overwhelm due to the manic state.
B.   Initiating physical exercise could help in redirecting excess energy, but it must be carefully monitored.
C.   Encouraging the client to spend time with others might increase stimulation and potentially exacerbate the mania.
D.   Clarity and specificity in communication are essential when caring for a client experiencing mania. Manic episodes can affect a client's ability to concentrate and process information. Providing clear instructions and explanations helps ensure the client understands what is expected and can follow through with necessary self-care and treatment activities.

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Correct Answer is C

Explanation

A. This statement describes a visual hallucination (seeing spiders crawling), not a command hallucination. Visual hallucinations involve seeing things that are not actually present.

B. This statement reflects a delusion rather than a hallucination. Delusions are false beliefs that are firmly held despite evidence to the contrary. In this case, the belief in aliens and abduction is not related to hearing voices commanding actions.
C. This statement indicates a command hallucination. The client hears voices instructing them to stop eating. Command hallucinations often involve direct, imperative commands from voices that are perceived as real.
D. This statement reflects paranoia or fear of harm from others, which can be a common symptom in schizophrenia. However, it does not directly indicate a command hallucination.

A. Keep staff interactions with the client to a minimum. B. Provide range-of-motion exercises to all extremities every 2 hr. C. Request the provider renew the prescription in 24 hr. D. Document the client's behavior in the medical record every 1 hr.

Correct Answer is C

Explanation

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

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A nurse is assisting in the care of a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take to promote a therapeutic environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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