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 C

Explanation

A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.

A. Sit in the chair next to the client. B. Listen to what the client is saying. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is B

Explanation

A. Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B. Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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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

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