A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
Turn on a dance video so the client can burn off excess energy.
Take the client outside and sit with her in the garden area.
Observe the client closely for the development of aggressive behavior.
Offer the client a low-calorie snack in return for stopping the behavior.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Panic. Panic-level anxiety typically involves extreme fear and severe physical symptoms such as palpitations, sweating, trembling, and a sense of impending doom. The client's reported symptoms (chest pain, headache, shortness of breath) do not align with the intense nature of panic anxiety.
B.Mild. Mild anxiety is characterized by heightened awareness and alertness. The client's symptoms and statement about his wife leaving him suggest more than mild anxiety as they indicate emotional distress beyond simple alertness.
C.Moderate. Moderate anxiety is associated with increased muscle tension, restlessness, and impaired concentration. Moderate anxiety (choice C) is characterized by increased alertness and decreased concentration but is manageable with support.
D. Severe anxiety significantly impairs daily functioning. It can cause physical symptoms such as chest pain, shortness of breath, and headaches. The client’s presentation aligns with severe anxiety, given the impact on his well-being.
Correct Answer is C
Explanation
A."Your mood must be lifting because you have on clean clothes and have combed your hair.": This makes an assumption about the client’s mood, which may not be accurate and can be interpreted as minimizing the client’s ongoing struggle.
B. "Oh, I'm so pleased that you finally put on clean clothes.": This response might come across as condescending or patronizing, which can negatively impact the therapeutic relationship.
C. "I see that you have on clean clothes and have combed your hair."This response is an example of therapeutic communication that acknowledges the client’s actions without making assumptions or passing judgment. It is an observational statement that recognizes the client's effort, which can help to encourage further positive behavior without imposing interpretations on the client's motivations.
D. "Why did you wear clean clothes and comb your hair today?": This could be interpreted as questioning the client's actions in a way that might make them feel defensive or uncomfortable.
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