An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

Document the threat in the medical record.

Inform the sister of the client’s threat.

Report the threat to the healthcare team.

Notify the healthcare provider of the threat.

Answer and Explanation

The Correct Answer is D

Choice A reason: Documenting the threat is important but less urgent than notifying the provider, who can initiate immediate safety measures for a client with bipolar disorder expressing harm intent. Notification ensures timely intervention, making documentation secondary and incorrect for the most important action.

Choice B reason: Informing the sister may breach confidentiality and is not the nurse’s role without legal or provider guidance. Notifying the provider ensures proper evaluation and safety planning, making this incorrect, as direct family notification is not the primary action in this scenario.

Choice C reason: Reporting to the healthcare team is less specific than notifying the provider directly, who can assess and manage the threat promptly. In bipolar disorder, rapid intervention is critical, making this less precise and incorrect compared to direct provider notification for immediate action.

Choice D reason: Notifying the healthcare provider is the most important action, as a threat to harm in bipolar disorder requires urgent evaluation for safety and potential mania-driven impulsivity. This ensures timely intervention, aligning with psychiatric safety protocols, making it the correct and most critical action.

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Correct Answer is C

Explanation

Choice A reason: Erythema of lesions suggests inflammation, often associated with disease-related hair loss like alopecia areata or infection. Ecchymotic accumulations point to trauma, indicating non-disease causes like trichotillomania. Erythema supports a pathological process, making this incorrect for identifying non-disease-related hair loss.

Choice B reason: Patches of lost hair are a symptom of hair loss but do not specify cause, as they occur in both disease (e.g., alopecia areata) and non-disease (e.g., trichotillomania) conditions. Ecchymosis indicates trauma, a non-disease cause, making this less specific and incorrect for ruling out disease.

Choice C reason: Ecchymotic blood accumulations suggest trauma, such as hair pulling in trichotillomania, a non-disease cause of hair loss in children. This finding distinguishes mechanical or behavioral etiology from pathological conditions like alopecia, aligning with pediatric dermatology evidence, making it the correct choice.

Choice D reason: Episodic pruritus suggests itching, often linked to dermatologic conditions like psoriasis or fungal infections causing hair loss. Ecchymosis indicates trauma, not disease. Pruritus supports a pathological process, making this incorrect for identifying a non-disease-related cause of the child’s hair loss.

A. Ask the client to describe and identify the source of the feelings. B. Assist the client with relaxation techniques in the group. C. Provide education about ways to cope with anxiety. D. Escort the client from the group to reduce stimuli.

Correct Answer is D

Explanation

Choice A reason: Asking the client to describe anxiety sources may increase distress in a severe anxiety state, as it requires cognitive effort under stress. Escorting from the group reduces stimuli, calming the client more effectively, making this incorrect for managing acute, severe anxiety during therapy.

Choice B reason: Relaxation techniques are useful but may be ineffective in a group setting for severe anxiety, where stimuli overwhelm the client. Escorting to a quieter area reduces triggers and facilitates calming, making this less optimal and incorrect compared to removing the client from the group.

Choice C reason: Educating about coping strategies is preventive, not immediate, for severe anxiety. Escorting the client from the group reduces stimuli, addressing acute distress directly. Education is impractical during a crisis, making this incorrect for the best intervention in a severe anxiety episode.

Choice D reason: Escorting the client from the group to a quieter area reduces environmental stimuli, helping de-escalate severe anxiety effectively. This intervention prioritizes immediate calming, aligning with psychiatric nursing principles for managing acute anxiety in group therapy, making it the best choice for this scenario.

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An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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