A nurse on a mental health unit is caring for a client.

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Encourage the client to take rest periods throughout the day

Weigh the client daily

Increase the client's environmental stimuli

Offer the client finger foods

Apply restraints to the client

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Choice A reason: Encouraging rest periods is anticipated because clients experiencing mania often have decreased need for sleep and heightened psychomotor activity. Structured rest periods help reduce exhaustion, stabilize mood, and prevent escalation of manic symptoms. Rest periods also promote recovery by counteracting the hyperactivity and insomnia commonly associated with mania.

Choice B reason: Daily weights are anticipated because clients with mania often neglect nutrition due to distractibility, hyperactivity, and poor insight. Monitoring weight provides objective data on nutritional status and helps the healthcare team intervene early if significant weight loss occurs. This is critical since malnutrition can worsen physical health and exacerbate psychiatric symptoms.

Choice C reason: Increasing environmental stimuli is contraindicated because clients with mania are already overstimulated. Additional stimuli can intensify agitation, distractibility, and restlessness, worsening the manic episode. The therapeutic environment should instead be calm, structured, and low-stimulation to promote focus and reduce hyperactivity.

Choice D reason: Offering finger foods is anticipated because clients with mania often cannot sit still long enough to consume a full meal. Finger foods allow them to eat while pacing or moving, ensuring adequate caloric intake despite their inability to remain seated. This intervention directly addresses nutritional deficits while accommodating the client’s psychomotor agitation.

Choice E reason: Applying restraints is contraindicated unless the client poses an immediate danger to themselves or others. Mania is best managed through therapeutic interventions such as medication, structured environment, and supportive care. Restraints can increase agitation, cause trauma, and damage the therapeutic relationship. They are not indicated in this scenario since the client is restless but not violent or self-harming.

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Correct Answer is ["A","C","D","F"]

Explanation

Choice A reason: Sitting with the client during mealtimes is an essential intervention because clients with bipolar disorder, especially during manic episodes, often have poor appetite and difficulty focusing long enough to eat. Direct support ensures nutritional intake, prevents further weight loss, and provides structure. It also reduces the risk of malnutrition and dehydration, which are common complications in manic states.

Choice B reason: Turning on the television for the client is not therapeutic. Clients in manic episodes are easily overstimulated, and television can increase agitation, distractibility, and hyperactivity. Instead of calming the client, it may worsen confusion and disorientation. Therefore, this intervention is inappropriate.

Choice C reason: Removing sharp objects from the client’s room is a critical safety measure. Clients with bipolar disorder experiencing mania may act impulsively, and the risk of self-harm or accidental injury is high. Ensuring the environment is free of dangerous objects reduces the likelihood of harm and supports safe management of the client’s agitation.

Choice D reason: Observing the client every 15 minutes is necessary for safety monitoring. The client is hyperactive, confused, and disoriented, which increases the risk of injury, aggression, or unpredictable behavior. Frequent observation allows early detection of escalating agitation and ensures timely intervention. This is a standard safety protocol in acute psychiatric care.

Choice E reason: Providing a low-protein diet is not indicated. Clients with bipolar disorder do not require protein restriction; in fact, adequate protein intake is important for maintaining energy and nutritional balance. Restricting protein could worsen malnutrition and weight loss. This intervention is inappropriate.

Choice F reason: Offering the client physical activities is beneficial because it provides a safe outlet for excess energy during manic episodes. Structured physical activity helps reduce agitation, channel hyperactivity, and promote better sleep. It also decreases restlessness and supports overall emotional regulation. Activities should be simple, noncompetitive, and safe to avoid overstimulation.

A. "A client loses the right to refuse prescribed medications when they are admitted involuntarily." B. "Clients admitted involuntarily are considered to be incompetent to provide informed consent." C. "A provider can write a prescription for restraints to use on a client on an as-needed basis." D. "If a client threatens to seriously harm someone, the provider should notify that person of the threat."

Correct Answer is D

Explanation

Choice A reason: Clients admitted involuntarily still retain the right to refuse medications unless a court order or emergency situation overrides this right. This statement is incorrect.

Choice B reason: Involuntary admission does not automatically mean a client is incompetent. Competency must be legally determined by a court, not assumed based on admission status.

Choice C reason: Restraints cannot be prescribed on an as-needed basis. They require a specific, time-limited order and must be used only when absolutely necessary to protect the client or others.

Choice D reason: Providers have a duty to warn identifiable individuals if a client makes a credible threat of serious harm. This is a legal and ethical responsibility to protect others from danger, making this the correct statement.

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A nurse on a mental health unit is caring for a client. For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The nurse is planning care for the client. Select the 4 interventions the nurse should include in the client’s care.

Correct Answer is ["A","C","D","F"]

Explanation

A charge nurse on a mental health unit is discussing legal issues with a newly licensed nurse. Which of the following statements should the charge nurse include?

Correct Answer is D

Explanation

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A nurse on a mental health unit is caring for a client.

For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.