Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

Educating the client to the policies upon admission to the unit.

Instructing the client that intrusive behaviors are not appropriate.

Ensuring that the client's medication therapy is administered in a timely manner.

Setting and maintaining consistent unit policies that are enforced by all staff.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
While educating the client about policies upon admission to the unit is important, it may not have the greatest impact on both the management of care and on milieu environment.
Choice B rationale:
Instructing the client that intrusive behaviors are not appropriate is important, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice C rationale:
Ensuring that the client’s medication therapy is administered in a timely manner is crucial, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice D rationale:
Setting and maintaining consistent unit policies that are enforced by all staff can create a stable and predictable environment, which can have a significant impact on both the management of care and on milieu environment.

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Correct Answer is B

Explanation

Choice A rationale:
Respiratory depression and a comatose state are not typically associated with agranulocytosis.
Choice B rationale:
Agranulocytosis, a potential side effect of clozapine, can cause symptoms like a sore throat and muscle aches due to the body’s decreased ability to fight off infections.
Choice C rationale:
Increased anxiety and suicidal ideations are not typically symptoms of agranulocytosis.
Choice D rationale:
Severe restlessness is not a common symptom of agranulocytosis.

A. "That is very interesting.We are not sure why people start to isolate themselves.”. B. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize.”. C. "Before symptoms of schizophrenia begin, people often isolate themselves.This is an early warning.”. D. "Were you avoiding your friend so that you could hear the voices more clearly?". .

Correct Answer is C

Explanation

Choice A rationale:

While it’s interesting to consider why people isolate themselves, this statement does not provide a clear explanation for the behavior.

Choice B rationale:

Being an introvert or extrovert doesn’t necessarily correlate with the onset of schizophrenia symptoms.

Choice C rationale:

Before symptoms of schizophrenia begin, people often isolate themselves. This is known as the prodromal phase of schizophrenia.

Choice D rationale:

Avoiding friends to hear voices more clearly is not a typical behavior associated with the onset of schizophrenia.

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Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

Correct Answer is B

Explanation

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a young adult client who has acute schizophrenic disorder and tells the nurse, "Yesterday noon the sun moon went over the rover to see the lawnmower.”. Which of the following manifestations is the client exhibiting?

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

A nurse is caring for a client who has borderline personality disorder (BPD). Check the 6 assessment findings that require immediate follow-up:.

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?