The nurse is planning the care for a client who is hospitalized with 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.)

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

Engage the client in competitive activities.

Assign the client to a single room.

Provide television programs with suspense to keep attention engaged.

Give concise and firm directions for hygiene and dressing.

Answer and Explanation

Correct Answer : A,C,E

A.   Inviting for a walk when the client's energy is high can help channel excess energy and reduce restlessness.
B.   Engaging the client in competitive activities might escalate the situation and isn't suitable for managing hyperactivity in bipolar disorder.
C.   Assigning the client to a single room can reduce external stimuli and potentially decrease overstimulation that might contribute to the behavior.
D.   Providing television programs with suspense might not effectively engage the client or address their needs.
E.   Giving concise and firm directions for hygiene and dressing can help provide structure and guidance during times of excessive energy or impulsivity.

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Correct Answer is D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

A. Client has been sexually assaulted. B. Client reported that she had sexual relations against her will. C. Client claims that she was forced to participate in sexual intercourse. D. Client states, "My date raped me tonight."

Correct Answer is D

Explanation

A. "Client has been sexually assaulted" is a formal and concise description. However, it isn’t written as a client would say it which is a key requirement in documentation of the presenting complaint.
B. "Client reported that she had sexual relations against her will" might be accurate but doesn't convey the severity of the situation as clearly as the term "sexually assaulted."
C. "Client claims that she was forced to participate in sexual intercourse" might describe the situation but doesn't necessarily reflect the urgency or trauma of the incident.
D. "Client states, 'My date raped me tonight'" is documented in the client’s own words and is descriptive enough to be the presenting complaint.

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The nurse is planning the care for a client who is hospitalized with 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 is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is D

Explanation

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

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The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

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