A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Attempt to talk the client down.

Administer a PRN antianxiety medication.

Place the client in a monitored seclusion room until he is calm.

Restrain the client to prevent injury to himself or others.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

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Correct Answer is A

Explanation

Choice A rationale:

Ideas of reference involve the belief that external events, objects, or people have a specific and unusual significance directly related to oneself. In this scenario, the client with schizophrenia believes that the group's laughter is directed at them, indicating an exaggerated sense of personal relevance in the situation.

Choice B rationale:

Erotomania is characterized by the delusional belief that someone, usually of higher social status, is in love with the individual. This choice is not applicable to the situation described, where the client's reaction is centered around perceived mockery rather than romantic interest.

Choice C rationale:

Grandeur involves inflated feelings of importance, power, knowledge, or identity. It does not align with the situation where the client perceives ridicule and responds defensively to the group's laughter.

Choice D rationale:

Flight of ideas is a thought disorder characterized by rapid and unconnected shifts in thoughts, often associated with mania. It is not relevant to the client's reaction to the group's laughter.

A. Impulsive behaviors. B. Dressing in black or grey clothing. C. Talking in rapid, continuous speech. D. Interacting with others in a flirtatious way. E. Sleeping for long periods of time.

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

Explanation

Choice A rationale:

Impulsive behaviors, such as sudden excessive spending, risky sexual encounters, or reckless driving, are common manifestations of manic behavior in individuals with bipolar disorder. These behaviors can result from the heightened energy and impulsivity associated with a manic episode.

Choice B rationale:

Dressing in black or grey clothing is not indicative of manic behavior. Mania is characterized by heightened mood, excessive energy, and impulsivity, rather than specific clothing choices.

Choice C rationale:

Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of manic episodes. Individuals may talk rapidly, switch topics frequently, and have difficulty allowing others to interject or participate in the conversation.

Choice D rationale:

Interacting with others in a flirtatious way can be a manifestation of manic behavior. During manic episodes, individuals may exhibit increased sociability, reduced inhibitions, and engage in behaviors that are out of character, including flirtatious interactions.

Choice E rationale:

Sleeping for long periods of time is not consistent with manic behavior. Manic episodes are often associated with decreased need for sleep, and individuals may experience insomnia or only require minimal sleep during these episodes.

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A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.).

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

Explanation

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?

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A psychiatric nurse is caring for clients on a mental health unit during a group session. What should the nurse do to establish trust in a therapeutic relationship with the clients?

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