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 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.

A. "I can always come stay in the hospital again if I don't want to take care of my own needs." B. "Right now, I can't bathe or dress myself, but my family will help me." C. "I will take my medicines as I should and know who to call if I have bad thoughts." D. "Taking care of myself is important, but it's okay if I don't want to do anything."

Correct Answer is C

Explanation

A. This statement suggests dependency and a lack of readiness to take responsibility for self-care.
B. While family support is important, the client should be able to demonstrate some level of independence for discharge readiness.
C. Taking medications as prescribed and knowing who to contact in case of suicidal thoughts shows insight and preparedness for discharge.
D. This statement reflects avoidance and a lack of motivation, indicating that the client is not yet ready for discharge.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge?

Correct Answer is C

Explanation

If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include?

A nurse is collecting data from a client who has histrionic personality disorder. Which of the following characteristics should the nurse expect?

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

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 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.)