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 C

Explanation

A. Isolating the client might exacerbate feelings of social exclusion and isn't the best approach for managing echolalia.
B. Administering a sedative should not be the initial response to echolalia unless the behavior poses immediate harm to the client or others.
C. Escorting the client to a private area can help reduce the annoyance to other clients without isolating or punishing the individual.
D. Avoiding recognition of the behavior doesn't address the issue and might negatively impact the therapeutic relationship.

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

Correct Answer is C

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

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