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

Explanation

A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.

B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.

C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.

D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.

A. Did you take your medicine this morning? B. i'm sure the voices sound scary, I don't hear any voices speaking C. The devil only talks to people who are receptive to his influence D. You are not going to hell. You are a good person

Correct Answer is B

Explanation

A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.

B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.

C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.

D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.

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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

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Correct Answer is B

Explanation

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