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
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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Related Questions
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.
Correct Answer is C
Explanation
A. This statement suggests dependency and a lack of readiness to take responsibility for self-care.
B. While family support is important, the client should be able to demonstrate some level of independence for discharge readiness.
C. Taking medications as prescribed and knowing who to contact in case of suicidal thoughts shows insight and preparedness for discharge.
D. This statement reflects avoidance and a lack of motivation, indicating that the client is not yet ready for discharge.
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