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 ["A","B","C"]

Explanation

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

A. Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation. B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation. C. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed. D. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Correct Answer is A

Explanation

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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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

Correct Answer is ["A","B","C"]

Explanation

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?

Correct Answer is A

Explanation

The nurse is caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

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