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 B

Explanation

Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.

Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.

Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.

Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.

A. Stimulation and dilated pupils. B. Bradycardia and bradypnea. C. Hallucinations and delusions. D. Lethargy and depression.

Correct Answer is A

Explanation

A. Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness.
B. Cocaine use is associated with tachycardia (increased heart rate) rather than bradycardia, and it usually increases respiratory rate rather than causing bradypnea.
C. Hallucinations and delusions are not typical effects of cocaine use; instead, they may occur with substances like hallucinogens or certain psychotic disorders.
D. Lethargy and depression are more commonly associated with the "crash" or comedown phase after cocaine use, rather than immediate effects of ingestion.

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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 male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is B

Explanation

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Correct Answer is A

Explanation

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

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?

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?

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?