A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

A client diagnosed I with hypomania who is speaking loudly on the unit.

A client diagnosed with hypomania who is complaining of pain.

A client with a history of mania who is pacing in the hallway

A client diagnosed with mania who expressed active suicidal ideations

Answer and Explanation

The Correct Answer is D

A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

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

Explanation

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself. B. I’m so sorry you cut your arms Let's discuss how you were feeling C. Wow. what happened to you?". D. What did you use to cut yourself! I will need to search your room

Correct Answer is A

Explanation

A. "After I clean your wounds, I would like for you to journal how you were feeling before you cut yourself."

This response is the most therapeutic. It acknowledges the patient's self-harm behavior, addresses the immediate physical needs by offering to clean the wounds, and encourages the patient to reflect on their emotions through journaling. This approach promotes self-awareness and provides a constructive coping strategy.

B. "I’m so sorry you cut your arms. Let's discuss how you were feeling."

This response is empathetic and encourages communication about the patient's emotions. While it acknowledges the self-harm and invites discussion, it does not suggest a specific coping strategy like journaling. It is still a supportive and therapeutic approach.

C. "Wow. What happened to you?"

This response may come off as judgmental or dismissive. It does not acknowledge the patient's emotional state or offer immediate support for the physical wounds. The tone and wording may make the patient feel uncomfortable or judged.

D. "What did you use to cut yourself! I will need to search your room."

This response is not therapeutic and may be perceived as confrontational and invasive. It does not prioritize the patient's emotional well-being and may violate the patient's trust and privacy. Searching the room without consent is not a recommended approach.

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A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

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

Explanation

A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?

Correct Answer is A

Explanation

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