A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

Stay quietly with the client.

Tell her that she is out of control.

Ignore the client's acting out, behavior.

Distract her by offering finger foods.

Answer and Explanation

The Correct Answer is A

A) Staying quietly with the client is the best approach in this situation. By remaining present and calm, the nurse can provide a sense of safety and support. This non-confrontational presence may help the client feel more secure and reduce her agitation over time.

B) Telling the client that she is out of control may escalate her frustration and feelings of being judged. This could worsen the situation rather than help it, as it does not offer any constructive feedback or support.

C) Ignoring the client's acting out behavior is not appropriate. Acknowledging her feelings and providing support is essential, even if her behavior is challenging. Ignoring her could lead to further escalation and feelings of isolation.

D) Distracting her by offering finger foods could be an effective strategy if the client is calm enough to engage in that activity. However, if she is currently shouting and screaming, she may not be receptive to distraction techniques. Addressing her emotional state first is more critical.

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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. Aspirin 81 milligrams PO daily. B. Losartan 50 mg PO daily. C. Phenelzine 60 mg PO daily. D. Hydrochlorothiazide 12.5 mg PO daily.

Correct Answer is C

Explanation

A) Aspirin 81 milligrams PO daily is commonly used as a low-dose antiplatelet medication and is generally not concerning in this context, especially with the symptoms described. It does not have a direct impact on blood pressure or the acute symptoms presented.

B) Losartan 50 mg PO daily is an antihypertensive medication used to manage high blood pressure. While the client’s blood pressure is elevated, this medication is appropriate for managing hypertension, and it does not pose an immediate concern.

C) Phenelzine 60 mg PO daily is of the most concern. It is a monoamine oxidase inhibitor (MAOI), which can have serious interactions with certain foods and medications, potentially leading to hypertensive crises, especially given the client’s high blood pressure of 216/108 mmHg. The client’s headache, nausea, and vomiting, combined with elevated vital signs, could indicate such a crisis, making this medication a significant concern.

D) Hydrochlorothiazide 12.5 mg PO daily is a thiazide diuretic commonly used to treat hypertension. While the client’s blood pressure is high, this medication is typically used to lower blood pressure and does not pose an immediate risk in this situation.

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A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

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 C

Explanation

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