A nurse is planning care for a client who is in the manic phase of bipolar disorder.

Which of the following interventions should the nurse include in the client's plan of care?.

Have consistent unit routines.

Provide a stimulating environment.

Schedule daily seclusion times.

Discourage daytime napping.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale:

Having consistent unit routines can provide a sense of stability and predictability, which can be beneficial for a client in the manic phase of bipolar disorder.

Choice B rationale:

Providing a stimulating environment can potentially exacerbate symptoms of mania, making it an inappropriate intervention.

Choice C rationale:

Scheduling daily seclusion times is not typically recommended as it can lead to feelings of isolation.

Choice D rationale:

Discouraging daytime napping can potentially lead to fatigue and worsen symptoms, so it’s not typically recommended.

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Correct Answer is D

Explanation

Choice A rationale:

Placing a client in restraints should be a last resort, as it can be traumatizing and can escalate agitation.

Restraints can also cause physical injury and psychological distress.

They should only be used when there is an immediate risk of harm to the client or others.

Choice B rationale:

Haloperidol is an antipsychotic medication that can be used to calm agitated clients.

However, it should not be the first-line intervention, as it can have significant side effects, including drowsiness, dizziness, and muscle stiffness.

It is important to assess the client's individual needs and risks before administering haloperidol.

Choice C rationale:

Asking a client to talk about their feelings can be helpful in some situations, but it is not appropriate when a client is agitated and yelling.

The client is likely to be too overwhelmed to engage in meaningful conversation.

It is important to first de-escalate the situation and ensure the safety of everyone involved.

Choice D rationale:

Moving the client to a seclusion room with continuous observation is the most appropriate intervention in this situation.

This will provide the client with a safe and quiet space to calm down.

It will also allow staff to monitor the client closely and intervene if necessary.

Continuous observation is essential to ensure the client's safety and to prevent self-harm.

A. Place the client in seclusion if she is experiencing visual hallucinations. B. Minimize staff supervision of the client’s interactions with others. C. Directly tell the client that delusions are not real. D. Limit the client’s participation in group activities.

Correct Answer is D

Explanation

The correct answer is D. Limit the client’s participation in group activities.

Explanation:

Clients with schizophrenia and paranoia may struggle in large group settings, where they could misinterpret interactions, feel threatened, or become agitated. Gradual integration into smaller, structured groups is typically recommended, rather than full exclusion, but limiting group participation can help reduce anxiety and prevent aggressive behaviors.

Why the other options are incorrect:

A. Place the client in seclusion if she is experiencing visual hallucinations – Seclusion is only used if the client poses a danger to themselves or others. Experiencing hallucinations alone does not warrant seclusion.
B. Minimize staff supervision of the client’s interactions with others – Increased supervision is necessary to ensure safety and monitor behavioral cues that may indicate escalating aggression.
C. Directly tell the client that delusions are not real – Confronting delusions outright can lead to agitation. Instead, acknowledge the client’s feelings while gently redirecting toward reality-based interactions.

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A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is caring for a client who begins to yell and scream at staff members. Which of the following actions is the nurse’s priority?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has schizophrenia and experiences paranoia with aggressive behavior. Which of the following interventions should the nurse recommend to be included in the plan of care?

Correct Answer is D

Explanation

Explanation:

Why the other options are incorrect:

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A nurse is planning care for a client who is in the manic phase of bipolar disorder.

Which of the following interventions should the nurse include in the client's plan of care?.