The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

Give concise and firm directions for hygiene and dressing.

Engage the client in competitive activities.

Assign the client to a single room.

Invite the client for a walk when client's energy is high.

Provide television programs with suspense to keep attention

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.

Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.

Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.

Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.

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Correct Answer is C

Explanation

Choice A rationale: Disrupting group activities is a concerning behavior but may not necessitate constant observation. The key is to assess the potential for harm to self or others.

Choice B rationale: Refusing antipsychotic medications is a significant concern, but it alone may not warrant constant observation. The nurse needs to assess the client's overall behavior and the potential for harm.

Choice C rationale: Wandering into clients' rooms poses a risk to the safety of both the client and others. This behavior indicates a need for constant observation to prevent harm or inappropriate interactions.

Choice D rationale: Talking with nonsensical words is a symptom of the client's mental health condition but may not be the sole criterion for constant observation. The nurse should assess the overall risk to safety.

A. Ask the client about his recent substance use. B. Perform a mental status exam. C. Assess the client from head-to-toe. D. Determine the number of previous hospitalizations.

Correct Answer is B

Explanation

Choice A rationale: Asking the client about recent substance use is essential in assessing potential intoxication or withdrawal, which could contribute to the client's confused state. However, performing a mental status exam is the most important action to take.

Choice B rationale: The most important action for the nurse to take is to perform a mental status exam. This will help the nurse to assess the client's level of consciousness, orientation, memory, attention, mood, affect, thought process, and judgment. The mental status exam will also help the nurse to identify any signs of psychosis, delirium, dementia, or other mental disorders that may explain the client's behavior. Choice C rationale: Assessing the client from head-to-toe is a general nursing action but does not address the immediate need related to potential substance use. Choice D rationale: Determining the number of previous hospitalizations is relevant but does not address the current concern of substance use contributing to confusion.

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The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

A 16-year-old female client is admitted to the psychiatric unit and states that she is depressed and anxious. The client appears frail and is wearing baggy clothes. When it is time for lunch, the client states, "I can't eat, I'm already overweight." What is the best response by the nurse?

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

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A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.