A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Explain the client that the behavior was unacceptable.

Explore the truth of the client's statements.

Set behavioral limits for the client.

Establish a client relationship

Answer and Explanation

The Correct Answer is C

A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.

B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.

C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.

D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.

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Correct Answer is C

Explanation

A. Antidepressants usually take several weeks to start taking effect, so the statement "I can be on my antidepressant taking three to five days to be effective" is not correct.

B. While positive thinking can play a role in managing mood, depression is a complex disorder that often requires more than just positive thoughts to treat. The statement "I can cure my depression by thinking positive thoughts" oversimplifies the condition.

C. "I will attend psychotherapy to help manage my depression."

Explanation:

Depressive disorders, including major depression, are complex conditions that typically require a multifaceted approach to treatment. Psychotherapy, also known as talk therapy, is an important component of treating depression. It involves working with a trained therapist to explore and address the thoughts, feelings, and behaviors contributing to the depression. Psychotherapy can help individuals develop coping strategies, improve problem-solving skills, and gain insight into their condition.

D. Depression is not something that can be simply chosen to be stopped voluntarily. It is a mental health disorder that often requires professional treatment and support. The statement "I need to make a voluntary choice to stop feeling depressed" does not accurately capture the nature of depression.

A. The client responds to questions with disorganized speech. B. The client reports that voices are telling him to write a novel. C. The client's spouse reports that client has recently gained weight. D. The client is dressed in all black.

Correct Answer is A

Explanation

A. The client responds to questions with disorganized speech:

Disorganized speech is a hallmark of acute mania, often reflecting racing thoughts, pressured speech, and difficulty staying on topic.

B. The client reports that voices are telling him to write a novel:

Reporting that voices are telling the client to write a novel suggests auditory hallucinations, which can occur in various psychiatric conditions, not specifically indicative of acute mania.

C. The client's spouse reports that the client has recently gained weight:

Weight gain is not a typical hallmark of acute mania. In fact, during manic episodes, individuals might experience decreased appetite and sleep, leading to potential weight loss.

D. The client is dressed in all black:

Dressing in all black is not a specific sign of acute mania. While changes in clothing choices or appearance can sometimes be associated with mood changes, this finding alone is not indicative of acute mania.

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A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates understanding of the teaching?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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