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 B

Explanation

A. Urinary output might be important in some contexts but is not the priority related to the use of MAO inhibitors.
B. MAO inhibitors like phenelzine can affect blood pressure significantly; monitoring BP is crucial due to the risk of hypertensive crisis when certain foods or medications are taken.
C. Respiratory rate might be a consideration in some situations but is not directly affected by MAO inhibitors.
D. Temperature is not typically a primary concern related to MAO inhibitor use; blood pressure monitoring is more crucial due to potential interactions.

A. Provide a quiet room away from the recreational area. B. Acquaint the client with the rules of the unit. C. Ensure that the client eats a well-balanced diet. D. Introduce the client to other clients with a similar diagnosis.

Correct Answer is A

Explanation

A. Providing a quiet room is important. This is because individuals with PTSD are often hypersensitive to noise and other stimuli, which can trigger flashbacks or other
symptoms. A quiet environment can help to reduce anxiety and promote relaxation.
B. Acquainting the client with the unit rules is important, but connecting the client with peers who understand their experiences can be more therapeutic initially.
C. Ensuring a well-balanced diet is essential but might not be the priority in the immediate plan of care for someone newly admitted with PTSD.
D. Introducing the client to others with similar diagnoses helps foster a sense of belonging.
However, this is a long-term rather than an immediate intervention.

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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

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer is B

Explanation

A client with post-traumatic stress disorder (PTSD) is admitted to the psychiatric unit. Which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is A

Explanation

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?

The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

A client with borderline personality disorder tells the nurse, "You are the best nurse on the unit! The other nurses don't care about me the way you do." Which response should the nurse provide to this client?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and lack of motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?