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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Telling parents not to talk about the attempt may reflect withdrawal or denial but does not necessarily indicate ongoing suicidal intent.
B. Giving away personal possessions, such as a CD collection, is a common behavior in adolescents with suicidal intent, as they may believe they won't need these items in the future.
C. Wanting to spend more time with peers than parents could indicate normal adolescent development, rather than a sign of suicidal intent.
D. Preferring to eat meals while watching TV is not a concerning behavior in the context of suicide risk.
Correct Answer is ["0.7"]
Explanation
To determine how many mL to administer, use the formula:
mL= Desired Dose/Available Dose per mL mL= 35mg/50 mg/mL
= 0.7 mL
Thus, the nurse should administer 0.7 mL of diphenhydramine.
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