A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

Move to a quiet area and provide peanut butter with crackers.

Encourage the spouse to eat lunch with the client.

Walk with the client to the cafeteria and stay while client eats.

Request a full lunch tray from the dietary department.

Answer and Explanation

The Correct Answer is C

A) Moving to a quiet area and providing peanut butter with crackers may help address the client’s nutritional needs, but it may not adequately address the client’s agitation and pacing. The immediate priority is to stabilize the client’s behavior before focusing on nutrition.

B) Encouraging the spouse to eat lunch with the client may create an opportunity for social interaction, but it might not be effective in calming the client’s agitation. If the client is already highly agitated, the spouse's presence alone may not help diffuse the situation.

C) Walking with the client to the cafeteria and staying while the client eats is the best intervention at this time. This approach allows the nurse to provide a calming presence and guidance while encouraging the client to eat. It also helps redirect the client's energy and agitation into a structured activity, promoting both physical movement and nutrition, which is crucial after several days without food.

D) Requesting a full lunch tray from the dietary department could provide a more substantial meal; however, it might not address the immediate need for calming the client. If the client remains agitated and loud, it may be challenging to ensure that they can eat peacefully, making this intervention less effective than accompanying the client directly to eat.

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Correct Answer is C

Explanation

A) Providing education on methods to enhance sleep may be helpful, especially since hypersomnia is a symptom. However, simply focusing on sleep does not address the broader functional impairments that the client is experiencing. While improving sleep hygiene can contribute to overall well-being, it is not the most comprehensive approach for facilitating a return to normal functioning.

B) Encouraging the client to exercise can be beneficial, as physical activity is known to have positive effects on mood and energy levels. However, for someone experiencing significant psychomotor retardation and amotivation, initiating an exercise routine can be daunting and may not be the most immediate or effective intervention. A structured approach is often more helpful in these cases.

C) Teaching the client to develop a plan for daily structured activities is likely to be the most effective intervention. Structured activities provide a framework that can help combat psychomotor retardation and amotivation by breaking down tasks into manageable parts. This approach encourages the client to engage in routine, which can gradually enhance motivation and overall functioning, helping them feel a sense of accomplishment and purpose.

D) Suggesting that the client develop a list of pleasurable activities could provide some motivation, but it may not be sufficient on its own, especially given the client's current level of amotivation. While identifying pleasurable activities is valuable, it is essential to pair this with a structured plan that encourages active participation and accountability, making the structured activities approach more effective in this context.

A. Tell the client that irrational thinking is a symptom of schizophrenia. B. Obtain an order for a tube feeding for the client. C. Assure the client that all food served in the hospital is safe to eat. D. Provide the client with food in unopened containers.

Correct Answer is D

Explanation

A) Telling the client that irrational thinking is a symptom of schizophrenia may come across as dismissive and could further alienate the client. While it's important to acknowledge the symptoms, this approach does not provide a practical solution to the immediate concern of the client refusing to eat.

B) Obtaining an order for tube feeding should be a last resort. While nutritional intake is essential, invasive interventions should only be considered if the client’s refusal to eat poses an immediate health risk and after other less invasive strategies have been attempted.

C) Assuring the client that all food served in the hospital is safe to eat might be well-intentioned, but it is unlikely to alleviate the client's fears. The client is experiencing

delusions, and simply stating that the food is safe may not be convincing.

D) Providing the client with food in unopened containers is the most appropriate intervention. This respects the client's concerns about food safety while offering a solution that allows them to eat without directly confronting their delusions. Unopened containers can provide a sense of security and control for the client, potentially encouraging them to consume food without feeling threatened.

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A client with bipolar disorder has not slept or eaten in four days. The client is pacing and becomes increasingly agitated and loud while the nurse talks to the client's spouse. Which intervention is best for the nurse to implement at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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