A nurse is caring for a client in a manic state of her Bipolar disorder. The client is dancing around the dayroom of the inpatient lounge. When she twirled her skirt it was obvious she was not wearing any underwear. The nurse enters the area and distracts her. She takes her to her room to put on underwear. Why did the nurse take this action?

To avoid her embarrassing herself in her manic state/behavior

Because there is no dancing allowed in the day room with other clients

To avoid her sexual passes at the clients

Because she was not following policy

Answer and Explanation

The Correct Answer is A

A.   The nurse’s primary concern is preventing the client from embarrassing herself due to the impulsive and disinhibited behaviors typical of a manic episode.
B.   There is no indication that dancing is prohibited; the issue is with inappropriate behavior.
C.   The focus of the action is not on sexual behavior but on ensuring the client is appropriately dressed in a social setting.
D.   Following policy is important, but the nurse’s action is more about protecting the client from social
embarrassment.

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Correct Answer is A

Explanation

A. Acknowledge the client’s delusion while gently redirecting them to the necessary activity (group
therapy). This approach maintains engagement without directly confronting the delusion.
B. Ignoring the delusion and focusing only on group therapy may cause the client to feel unheard or dismissed.
C. Dismissing the delusion is not therapeutic and could undermine trust.
D. Asking "why" could challenge the delusion, leading to defensiveness rather than productive conversation.

A. "You really should work hard to stay on the schedule we establish here." B. "I wouldn't worry about what you've done in the past. You'll do just fine this time." C. "Why do you find it difficult to take your medications if they improve your condition?" D. "Let's work together to devise a schedule that is convenient for you on a daily basis."

Correct Answer is D

Explanation

A. Telling the client to "work hard" to stay on schedule does not address the underlying difficulty with medication adherence.
B. Saying not to worry about past issues may minimize the client’s concerns and challenges.
C. Asking "why" the client finds it difficult to take medications might not encourage open communication and could make the client feel judged.
D. Collaborating with the client to create a schedule that is convenient and achievable increases the likelihood of adherence and fosters a sense of control and partnership.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has delusional behavior. The client states, "I can't go to group today. I am expecting a high level official to visit me!" Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is discussing quality of life with a client who has schizophrenia. Which of the following statements should the nurse include?

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?

A nurse must be alert when a client is giving away possessions, getting his/her life in order, or making vague goodbyes to people. Which of the following should the nurse be concerned about?

A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

A nurse is caring for a client who is experiencing auditory hallucinations. Which of the following responses should the nurse make first?

A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse on a mental health unit is caring for a client who refuses to follow instructions and states that the unit rules do not apply to them. The nurse should identify that these findings are manifestations of which of the following personality disorders?