Exhibits

A nurse is planning care for a client who has been readmitted to an acute mental health unit. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Use verbal intervention to assess the client's behavior.

Stand in front of the patient while acknowledging their behavior.

Ignore the client's escalating behavior

Approach the client with security.

Answer and Explanation

The Correct Answer is A

A. Use verbal intervention to assess the client's behavior. The first step in managing aggressive behavior is verbal de-escalation. Speaking calmly, using open-ended questions, and acknowledging the client’s emotions can help prevent further escalation and reduce agitation. Since the client has a history of aggression and medication nonadherence, early intervention is key to maintaining safety.
B. Stand in front of the patient while acknowledging their behavior. Standing directly in front of an aggressive client can be perceived as confrontational and threatening, which may provoke further aggression. Instead, the nurse should stand at an angle and maintain a safe distance while maintaining a calm, non-threatening posture.
C. Ignore the client's escalating behavior. Ignoring escalating aggression can put staff and other clients at risk. While not reinforcing negative behaviors is important in some cases, failing to intervene can lead to physical outbursts and loss of control.
D. Approach the client with security. While security may be needed if the client becomes physically violent, the first step in de-escalation should always be verbal intervention. Using security too soon can increase agitation and make the client feel threatened or cornered, escalating the situation unnecessarily.

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Correct Answer is D

Explanation

A. Illusion. An illusion is a misinterpretation of a real external stimulus (e.g., mistaking a coat rack for a person). The client’s statement does not indicate an illusion but rather an intent to cause self-harm.
B. Hallucination. A hallucination involves perceiving something that is not present, such as hearing voices or seeing objects that are not there. The client is not experiencing a sensory perception disturbance but rather expressing suicidal or self-harming thoughts.
C. Attention-seeking behavior. While some individuals may engage in self-harming behaviors as a way to seek help or express distress, the nurse must never assume a self-harm statement is purely attention-seeking. Every expression of self-harm must be taken seriously and assessed further.
D. Self-mutilation. The client’s statement suggests an intent to inflict harm on themselves using a sharp object. Individuals with bipolar disorder, particularly in a depressive or mixed episode, may engage in self-injurious behaviors as a way to cope with emotional distress. This requires immediate intervention to ensure safety.

A. Voice alteration B. Neck pain C. Memory deficit D. Headache

Correct Answer is C

Explanation

A. Voice alteration. ECT does not directly affect the vocal cords. While general anesthesia and muscle relaxants are used during the procedure, they do not typically result in long-term voice changes. Any hoarseness would likely be due to temporary irritation from the endotracheal tube if intubation was used.
B. Neck pain. While some muscle soreness can occur due to the seizure activity induced by ECT, neck pain is not a common or primary adverse effect. The use of muscle relaxants minimizes physical strain during the seizure.
C. Memory deficit. Short-term memory loss is a well-known side effect of ECT. Clients often experience difficulty recalling recent events (anterograde amnesia), but this usually improves over time. Some clients may also have retrograde amnesia, affecting memories from before the procedure, though this is typically less severe.
D. Headache. Mild headaches can occur after ECT due to electrical stimulation of the brain and anesthesia recovery. However, while headaches are possible, they are not as significant as memory impairment, making memory deficit the best answer.

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Exhibits A nurse is planning care for a client who has been readmitted to an acute mental health unit. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The client says to the nurse. "Give me your pen to cut the pain out of my chest." The nurse should identify that the client is at risk for which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client who has undergone electroconvulsive therapy (ECT). The nurse should monitor the client for which of the following adverse effects of ECT?

Correct Answer is C

Explanation

A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

A charge nurse in a community mental health clinic is discussing ethical concepts of client care with a newly licensed nurse. The charge nurse should use which of the following situations as an example of fidelity?

A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply).

A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?

A nurse is providing teaching to the caretakers of a client who has Alzheimer's disease with mild cognitive decline. The client is beginning to experience sleep disturbances. Which of the following instructions should the nurse include?

A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?

A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

A nurse is discussing discipline techniques with the parent of a pre-schooler. Which of the following statements by the parent indicates an understanding of time-out as a form of discipline?

Exhibits

A nurse is planning care for a client who has been readmitted to an acute mental health unit. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)