A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Illusion

Hallucination

Attention-seeking behavior

Self-mutilation

Answer and Explanation

The Correct Answer is D

Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

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Correct Answer is A

Explanation

Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.

A. Admission of client to a locked inpatient psychiatric unit B. Placement of client in a secured padded room in response to threats of self-harm C. Involuntary commitment to an outpatient community mental health center D. Medication administration for sedation so the client cannot get out of bed

Correct Answer is C

Explanation

Choice A reason:
Admission to a locked inpatient psychiatric unit is a more restrictive environment. While necessary for some clients, it limits their freedom and autonomy. The least restrictive environment principle seeks to avoid such settings unless absolutely necessary.

Choice B reason:
Placement in a secured padded room is highly restrictive and typically used only in extreme cases where the client poses an immediate danger to themselves or others. This setting is far from the least restrictive environment.

Choice C reason:
Involuntary commitment to an outpatient community mental health center represents a less restrictive environment. It allows the client to receive necessary treatment and support while remaining in the community, maintaining a higher level of independence and normalcy.

Choice D reason:
Medication administration for sedation to the point where the client cannot get out of bed is a highly restrictive intervention. It significantly limits the client’s autonomy and is not aligned with the principle of providing care in the least restrictive environment.

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A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?

Correct Answer is A

Explanation

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

Correct Answer is C

Explanation

On review of the client’s record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

After experiencing increasing conflict in the home, a social worker calls and schedules a therapy meeting. A 24-year-old, his sister, his mother, and the mother’s live-in boyfriend are asked to attend the therapy meeting. Who is the “client” who will be treated during this session?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who has a new prescription for chlorpromazine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to chlorpromazine?