A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"
Which of the following would be the most therapeutic response by the nurse?
"You need to come and take a shower before you can go get your hair cut."
"Please stop banging on the door. Your room is right over there."
"The door is locked so that you don't leave and get hurt."
"You are in the hospital, and I'm your nurse."
The Correct Answer is C
A. This response does not directly address the client's concern and may be perceived as dismissive.
B. This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C. This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D. This response acknowledges the situation but does not provide a clear explanation for the locked door.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "It sounds as though the antidepressants are working well. Just ask the client if the client is experiencing any side effects and let me know." This response does not adequately address the change in mood and the potential for hypomania. It assumes the change is solely due to the antidepressants.
B. "I'm concerned. Sometimes depressed people seem contented when they have decided to commit suicide. Let's schedule an appointment for tomorrow." While it's important to assess for suicidality, the description provided does not indicate immediate suicidal intent. The client's behavior is more indicative of hypomania.
C. "Since the client is eating, sleeping, and not behaving inappropriately, there's nothing to worry about. Just let me know if the client starts getting irritable or has trouble sleeping." This response downplays the significance of the mood change and does not address the potential for hypomania.
D. "The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication." This response correctly identifies the potential for hypomania and takes appropriate action by scheduling an evaluation. Adjusting the client's medication may be necessary to address the change in mood.
Correct Answer is ["A","C","D"]
Explanation
A. Establish a healthy sleeping, eating, and exercise routine This is an important relapse prevention strategy as it promotes physical and emotional wellbeing. A structured routine helps maintain stability and reduces the risk of returning to substance use.
B. Prevent overscheduling and becoming fatigued and exhausted. Reach out to reconnect with old buddies to test strength in resistance This statement includes potential triggers for relapse (reconnecting with old buddies) and does not align with effective relapse prevention strategies.
C. Have a friend or counselor number to call when having doubts This is a valuable strategy as it provides the client with a support system and someone to reach out to during moments of doubt or vulnerability.
D. Attend outpatient and community support groups for addiction Support groups provide a sense of community, understanding, and accountability for individuals in recovery. They offer a safe space to share experiences and coping strategies, making them an essential part of relapse prevention.
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