A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

You are being unreasonable, and I will not call your doctor at this hour."

Go back to your room, and I'll try to get in touch with your doctor."

You must be very upset about something

I can't call a doctor in the middle of the night unless it's an emergency."

Answer and Explanation

The Correct Answer is C

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.

B. "Go back to your room, and I'll try to get in touch with your doctor."

This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.

C. "You must be very upset about something."

This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.

D. "I can't call a doctor in the middle of the night unless it's an emergency."

While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.

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Correct Answer is C

Explanation

A) "My child was born with a birth defect due to an exposure I had overseas."

This statement does not directly relate to the core symptoms of PTSD. While exposure to trauma can have a variety of consequences, including potential exposure-related health issues, this statement does not necessarily indicate the re-experiencing, avoidance, or hyperarousal symptoms characteristic of PTSD.

B) "I check any room I enter because the enemy is still after me and could be hiding anywhere."

This statement is more indicative of hyperarousal and hypervigilance, which are common symptoms of PTSD. However, it does not explicitly involve re-experiencing the traumatic event through nightmares or intrusive memories, as described in the correct answer.

C) "In my dreams, all I can see are the wounded reaching out and trying to grab me."

Explanation:

The statement "In my dreams, all I can see are the wounded reaching out and trying to grab me" indicates symptoms commonly associated with posttraumatic stress disorder (PTSD). This statement reflects the re-experiencing symptom cluster of PTSD, where individuals may have distressing and intrusive memories, nightmares, or flashbacks related to the traumatic event they experienced. The imagery of wounded individuals trying to grab the person suggests a strong emotional impact and ongoing distress related to the traumatic experience.

D) "I killed four enemy soldiers with my bare hands and saved my entire battalion."

While this statement might reflect exposure to a traumatic event and could contribute to symptoms of PTSD, it is presented in a way that seems more like a narrative of heroic actions rather than a symptom of distress or re-experiencing.

A. “I need to make sure that the potential victim is warned." B. "I need to keep the information confidential due to the client's right to privacy." C. “I can only discuss the client's threats with a court order." D. "I should verbally report this information to the psychiatrist."

Correct Answer is A

Explanation

A. "I need to make sure that the potential victim is warned."

Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.

B. "I need to keep the information confidential due to the client's right to privacy."

Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.

C. "I can only discuss the client's threats with a court order."

Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.

D. "I should verbally report this information to the psychiatrist."

Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.

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A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

Nursing Test Bank

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Correct Answer is A

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