A nurse is caring for a client in a manic state of her Bipolar disorder. The client is dancing around the dayroom of the inpatient lounge. When she twirled her skirt it was obvious she was not wearing any underwear. The nurse enters the area and distracts her. She takes her to her room to put on underwear. Why did the nurse take this action?

To avoid her embarrassing herself in her manic state/behavior

Because there is no dancing allowed in the day room with other clients

To avoid her sexual passes at the clients

Because she was not following policy

Answer and Explanation

The Correct Answer is A

A.   The nurse’s primary concern is preventing the client from embarrassing herself due to the impulsive and disinhibited behaviors typical of a manic episode.
B.   There is no indication that dancing is prohibited; the issue is with inappropriate behavior.
C.   The focus of the action is not on sexual behavior but on ensuring the client is appropriately dressed in a social setting.
D.   Following policy is important, but the nurse’s action is more about protecting the client from social
embarrassment.

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Correct Answer is C

Explanation

A. Encouraging physical activity, like a daily walk, is a positive way to support the client’s mental health
and can help with symptoms of depression.
B. Setting timers for medications and meals is a helpful strategy to ensure the client adheres to the prescribed treatment plan.
C. Letting the client have complete freedom without offering support or asking questions is a risky approach. The nurse should encourage family involvement and monitoring, as clients recovering from a suicide attempt need continued emotional support and guidance.
D. Engaging with the client about their feelings and daily goals can help maintain communication and provide emotional support.

A. "He spends much of his time with his school friends." B. "He is very religious and attends services twice a week." C. "He has slept 9 hours each night for the past 2 years." D. "His basketball coach committed suicide last month."

Correct Answer is D

Explanation

A. Spending time with friends is generally a healthy social behavior.
B. Being religious and attending services does not indicate suicidal risk.
C. Sleeping 9 hours per night is within a normal range for an adolescent.
D. The statement about the basketball coach committing suicide may indicate the adolescent is at risk for suicide, as exposure to suicide can increase the likelihood of suicidal behavior.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching the family of a client about the signs and symptoms of major depression prior to the discharge of their loved one from an inpatient stay after a suicide attempt. Which statement by a family member warrants further education by the nurse?

Correct Answer is C

Explanation

A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?

Correct Answer is D

Explanation

A nurse assisting in the care of a client who has a mood disorder. Which of the following client statements by the client indicates readiness for discharge?

A nurse is collecting data on a client and finds that Ari is always manic but has had one depressive episode in the last year. Which of the following diagnosis should the nurse suspect?

A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?

A nurse is assisting with the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse recommend to include?

A nurse is assisting with planning of care for a client following a suicide attempt. Which of the following interventions is an appropriate suicide precaution?

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?