After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Instruct the client to reduce the volume of his voice.

Accompany the client to a quiet area of the unit.

Encourage the client to attend a support group.

Administer a PRN sedative by injection.

Answer and Explanation

The Correct Answer is B

A.   Instructing the client to reduce the volume of his voice may not be effective during a manic episode and could escalate the situation.
B.   Accompanying the client to a quiet area of the unit provides a more supportive and calming environment, allowing the client to deescalate.
C. Encouraging the client to attend a support group is a positive intervention but may not be immediately effective during an agitated state.
D.   Administering a PRN sedative by injection may be considered, but less restrictive interventions should be attempted first to promote a therapeutic environment.

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Correct Answer is B

Explanation

A. Participating in individual and group therapy is important for overall mental health, but the immediate focus is on addressing the self-harming behavior.
B. Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
C. Taking all antianxiety medications as prescribed is important but may not directly address the client's self-harming behavior.
D. Learning methods of relaxation is valuable, but the most immediate concern is preventing self-harm. The client should demonstrate effective ways to cope with anxiety to reduce the risk of self-injury.

A. The healthcare provider’s history and physical. B. Recent urine drug testing (UDT) results C. Baseline nursing admission assessment D. Abnormal Involuntary Movement Scale (AIMS)

Correct Answer is D

Explanation

A. The healthcare provider's history and physical may provide information about the client's overall health but may not specifically address the observed symptoms.
B. Recent urine drug testing (UDT) results may reveal drug use but may not be directly related to the observed involuntary movements.
C. The baseline nursing admission assessment may provide general information but may not specifically address medication side effects.
D. The Abnormal Involuntary Movement Scale (AIMS) is specifically designed to assess and document involuntary movements associated with psychotropic medications, making it the most relevant assessment tool in this situation.

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After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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