Which of the following actions should the nurse take to address the safety needs of an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused?

Move the client to a room closer to the nurse's station.

Apply wrist and leg restraints to the client.

Administer medication to sedate the client.

Call the family and ask them to stay with the client.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Moving the client to a room closer to the nurse's station is a non-invasive measure that allows for closer observation and quicker intervention if the client's condition worsens. It provides safety without compromising the client's autonomy or dignity.

Choice B reason:

Applying wrist and leg restraints is generally considered a last resort due to the potential for physical and psychological harm. Restraints can increase agitation and confusion, and they carry a risk of injury. They should only be used when less restrictive measures have failed and the client is at immediate risk of harm to themselves or others.

Choice C reason:

Administering medication to sedate the client may be appropriate in certain situations, but it should not be the first action taken. Sedation can mask underlying conditions and may lead to further complications. It is important to assess the cause of the client's restlessness and confusion before considering sedation.

Choice D reason:

Calling the family to ask them to stay with the client can provide comfort and may help to orient the client. However, this may not always be feasible, and it does not address the immediate safety needs of the client in the same way that moving them closer to the nurse's station does.

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Correct Answer is A

Explanation

Choice A Reason:

Disorganized speech is a common symptom of acute mania in bipolar disorder. It reflects the racing thoughts and the inability to filter or organize ideas before speaking. This symptom can manifest as rapidly changing topics, speaking incoherently, or displaying a flight of ideas.

Choice B Reason:

While changes in interest in sexual relations can occur in bipolar disorder, a loss of interest is more commonly associated with depressive episodes rather than manic episodes. During manic episodes, individuals may actually exhibit an increased interest in sexual activity.

Choice C Reason:

Hearing voices, or auditory hallucinations, can be a symptom of acute mania, especially if the content of the hallucinations is grandiose or related to the individual's inflated self-esteem or sense of importance. However, this symptom is not as common as disorganized speech and is more often associated with psychotic features.

Choice D Reason:

Weight gain is not a symptom typically associated with acute mania. In fact, during manic episodes, individuals may experience weight loss due to high energy levels, decreased need for sleep, and increased physical activity.

A. Prior physical health followed by the need for two surgeries within the last three months. B. Sudden unexplained loss of peripheral sensation. C. Obsession over a fictitious defect in physical appearance. D. Continuous worry about the undiagnosed presence of an illness.

Correct Answer is D

Explanation

Choice A reason:

A history of prior physical health issues and surgeries may contribute to health-related anxieties, but they are not specific findings expected in illness anxiety disorder. This disorder is characterized by excessive worry about having a serious illness, not necessarily a history of actual health problems.

Choice B reason:

Sudden unexplained loss of peripheral sensation could be a symptom of a neurological condition and is not a typical finding in illness anxiety disorder. Individuals with this disorder are preoccupied with the idea of being ill rather than experiencing unexplained physical symptoms.

Choice C reason:

An obsession over a fictitious defect in physical appearance is more indicative of body dysmorphic disorder rather than illness anxiety disorder. While both disorders involve preoccupation with health and appearance, illness anxiety disorder focuses on the fear of having a serious illness.

Choice D reason:

Continuous worry about the undiagnosed presence of an illness is a central feature of illness anxiety disorder. Individuals with this disorder are excessively concerned about the possibility of having a serious, undiagnosed medical condition despite lack of or minimal somatic symptoms

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Which of the following actions should the nurse take to address the safety needs of an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

Correct Answer is A

Explanation

Which of the following findings should a nurse expect when assessing a client with illness anxiety disorder?

Correct Answer is D

Explanation

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