A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest. The nurse should identify that the client is at risk for which of the following?

Illusion

Hallucination

Attention-seeking behavior

Self-mutilation

Answer and Explanation

The Correct Answer is D

A. Illusion: An illusion is a misinterpretation or misperception of a real external stimulus. It involves a distortion of sensory perception, but the client's statement does not suggest a misperception of reality.

B. Hallucination: A hallucination is a sensory perception in the absence of any external stimulus. It involves experiencing something that is not present in reality. The client's statement does not indicate experiencing a sensory perception that is not real.

C. Attention-seeking behavior: While the client's statement may draw attention to their distress, it is important not to dismiss it as merely attention-seeking behavior. The client's request for the pen to alleviate emotional pain suggests a deeper psychological issue and a genuine risk for self-harm.

D. Self-mutilation: Self-mutilation refers to intentional self-inflicted injury or harm to one's body tissue without the intent to die. The client's statement about using the pen to cut the pain out of their chest indicates a clear risk for self-mutilation.

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Correct Answer is C

Explanation

A. Remain 15 cm (6 in) away from the client: Maintaining a safe physical distance is important to ensure the safety of both the client and the staff member. However, the specific distance may vary depending on the situation and the client's level of agitation. It's essential to maintain a safe distance while still engaging with the client in a supportive manner.

B. Use a raised voice when speaking to the client: Using a raised voice can escalate the situation further and may increase the client's agitation or aggression. It's important to speak calmly and softly to avoid escalating the situation.

C. Determine the cause of the client's feelings: Understanding the underlying reasons for the client's aggression can help the nurse address the root cause and implement appropriate interventions. It's important to listen actively to the client, validate their feelings, and demonstrate empathy.

D. Ask the client short close-ended questions: Close-ended questions typically elicit simple "yes" or "no" responses and may not encourage open communication or help the client express their feelings. Instead, it's more beneficial to ask open-ended questions that allow the client to express themselves and feel heard.

A. The client has a serotonin deficiency B. The client has acute bronchitis C. The client has an elevated calcium level D. The client is an only child

Correct Answer is A

Explanation

A. The client has a serotonin deficiency

This choice suggests a biological risk factor for major depressive disorder (MDD). Serotonin is a neurotransmitter associated with mood regulation, and alterations in its levels or function can contribute to the development of depressive symptoms. A deficiency in serotonin is considered a significant biological risk factor for MDD.

B. The client has acute bronchitis

Acute bronchitis, an inflammation of the bronchial tubes typically caused by viral infections, is not directly associated with major depressive disorder. While physical health issues can impact mental health and exacerbate depressive symptoms, acute bronchitis is not a recognized risk factor for MDD.

C. The client has an elevated calcium level

Elevated calcium levels are not typically considered a risk factor for major depressive disorder. While imbalances in electrolytes like calcium can have physiological effects on the body, they are not directly linked to the development of depression.

D. The client is an only child

Being an only child is a demographic characteristic and is not considered a direct risk factor for major depressive disorder. While family dynamics and relationships can influence mental health, being an only child alone is not causally related to the development of depression.

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A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest. The nurse should identify that the client is at risk for which of the following?

Nursing Test Bank

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