A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Plan with the client for how he can better handle frustration.

Place the client in a monitored seclusion room until he is calm.

Offer the client an antianxiety medication.

Restrain the client to prevent injury to himself or others.

Answer and Explanation

The Correct Answer is C

A. Planning with the client for how he can better handle frustration is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Grandiosity.
Grandiosity is a symptom commonly seen in the manic phase of bipolar disorder. It involves an inflated sense of self-importance, unrealistic beliefs in one's abilities, and a perception of being involved in activities that are revolutionary or of great significance. In this scenario, the client's statement about revolutionizing the industry reflects grandiosity.

B. Clang associations involve the association of words based on sound rather than meaning and are often seen in individuals with thought disorders.

C. Flight of ideas refers to a rapid flow of thoughts, often manifested by speech that is difficult to interrupt, with topics changing rapidly.

D. Confabulation is the creation of false or distorted memories without the intention to deceive. It is not a characteristic behavior of mania in bipolar disorder.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort

Explanation:

St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.

In the given scenario, the nurse should identify:

Condition: The client's intake of St. John's wort

Client Finding: At risk for developing serotonin syndrome

This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.

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A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

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