A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

"I understand that you're angry and unhappy. Let's explore ways in which you overreact."

"I hear your frustration about losing control. Tell me how this affects your daily life."

"Knowing the cause of your symptoms will make them easier to handle."

"Do all that you can to learn all that you can while you are here. You can get better."

Answer and Explanation

The Correct Answer is B

A.   This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B.   This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C.   While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D.   While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

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Correct Answer is D

Explanation

A. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C. While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D. Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

A. Episodic intervals of pruritus. B. Erythema of the localized lesions. C. Ecchymotic blood accumulations. D. Evidence of patches of lost hair.

Correct Answer is C

Explanation

A. Episodic intervals of pruritus (itching) may suggest a dermatological condition or irritation of the scalp, but they do not directly indicate that the hair loss is not disease-related.
B. Erythema (redness) of the localized lesions may suggest inflammation or irritation but does not necessarily indicate that the hair loss is not disease-related.

C. Ecchymotic blood accumulations (bruising) suggest trauma or repeated pulling at the hair, which is not typically associated with disease-related causes. This finding can indicate a behavioral issue, such as trichotillomania (a compulsive hair-pulling disorder), where physical damage to the scalp can result in bruising and bald patches. The presence of ecchymosis supports a mechanical, non-disease-related cause of hair loss.

D. Evidence of patches of lost hair alone does not confirm whether the hair loss is disease-related or non-disease-related. Patches of hair loss can occur with both behavioral conditions (e.g., trichotillomania) and diseases (e.g., alopecia areata, fungal infections).

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A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Correct Answer is D

Explanation

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

Correct Answer is C

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?

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Mark which behaviors might be related to alcohol intoxication, acute phase of rape- trauma syndrome, or both. Tick only 1 box.

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A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

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