A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

it will help you feel better if you talk about it

"Come on out and get involved with the game the other clients are playing

"Til stay with you for a few minutes."

Till come back when you feel like talking."

Answer and Explanation

The Correct Answer is C

A. "It will help you feel better if you talk about it." While talking can be therapeutic, pushing the client to talk when they're not ready may be counterproductive and increase their distress.

B. "Come on out and get involved with the game the other clients are playing." Encouraging the client to engage in activities may not be suitable when she is expressing a need for solitude and is not ready to participate.

C. "I'll stay with you for a few minutes."
This response reflects the nurse's willingness to provide support without pressuring the client to talk. It acknowledges the client's feelings and offers a comforting and nonintrusive presence. It respects the client's desire for solitude while still showing empathy and availability.

D. "I'll come back when you feel like talking." This response leaves the client alone, which may
be appropriate if that's what the client prefers. However, offering to stay for a few minutes communicates immediate support without pressure.

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Correct Answer is B

Explanation

A. Loss of appetite is not a specific manifestation of lithium toxicity. However, gastrointestinal symptoms like nausea and vomiting can contribute to a decreased appetite.

B. Vomiting and diarrhea.
Lithium is a mood stabilizer commonly used in the treatment of bipolar disorder. Toxicity can occur, and symptoms can range from mild to severe. Vomiting and diarrhea are common early signs of lithium toxicity. As toxicity progresses, it can lead to more severe symptoms, such as tremors, confusion, and potentially life-threatening complications.

C. Increased flatulence is not a typical manifestation of lithium toxicity. Gastrointestinal symptoms associated with lithium toxicity are more likely to include nausea, vomiting, and diarrhea.

D. Increased urination is not a typical manifestation of lithium toxicity. Lithium can affect renal function, leading to decreased urine output, but it does not typically cause increased urination as a sign of toxicity.

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently. B. Play loud music for the client in her room. C. Engage the client in a small group activity. D. Instruct the client to avoid napping during the day.

Correct Answer is A

Explanation

A. Offer the client high-calorie foods that he/she can eat with their hands and fluids frequently.
Clients experiencing acute mania often have increased energy levels and may engage in hyperactive behaviors, leading to a high calorie expenditure. Offering high-calorie foods that can be eaten with hands and fluids frequently can help meet the increased energy needs of the client. It's important to ensure proper nutrition and hydration during the manic episode.

B. Playing loud music for the client in her room may exacerbate the heightened arousal and agitation associated with mania. It is important to create a calm and structured environment.

C. Engaging the client in a small group activity may be overwhelming and contribute to increased stimulation. Individual activities or smaller, quieter groups may be more appropriate for a client in acute mania.

D. Instructing the client to avoid napping during the day may not be practical. Clients in acute mania often have reduced need for sleep, and forcing them to avoid napping may increase agitation and restlessness. It's essential to balance rest with activity and monitor for signs of exhaustion.

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A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

A nurse is caring for a client who has a serious mental illness and has developed tardive dyskinesia from anti-psychotic medication use. Which of the following adverse effects from anti-psychotic medication use would be expected for the client?

A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse Include?

A nurse is assisting in the development of a community education course about the physical complications related to substance use disorder. Which of the following complications should the nurse include in the discussion about heroin use?