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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
This response provides general information about the hereditary nature of mental illnesses and reassures the client of the nurse’s experience. It maintains a professional boundary and does not disclose personal information, making it a therapeutic response.
Choice B reason:
This response acknowledges the client’s concern about the hereditary nature of mental illness and redirects the focus back to the client’s current situation. It is a therapeutic response that maintains professional boundaries and keeps the conversation client-centered.
Choice C reason:
This response validates the client’s concern and encourages further discussion about their feelings and experiences. It is a therapeutic response that promotes open communication and understanding.
Choice D reason:
Disclosing personal information about the nurse’s family can blur professional boundaries and shift the focus away from the client. It is considered nontherapeutic because it may make the client feel uncomfortable or distract from their own issues.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason:
An electroencephalogram (EEG) monitor is essential for monitoring the brain’s electrical activity during ECT. This equipment helps ensure that the treatment is administered safely and effectively by providing real-time data on the patient’s brain waves. The EEG monitor is crucial for assessing the patient’s response to the therapy and detecting any abnormalities.
Choice B reason:
An ophthalmoscope is used to examine the interior structures of the eyes, which is not relevant to the ECT procedure. Therefore, it is not necessary to set up an ophthalmoscope in the room prior to ECT. The focus of ECT preparation is on monitoring the patient’s neurological and cardiovascular status, not on eye examinations.
Choice C reason:
A cardiac monitor is vital for tracking the patient’s heart rate and rhythm during ECT. This equipment helps detect any cardiac abnormalities or arrhythmias that may occur as a result of the treatment. Continuous cardiac monitoring ensures that any potential complications can be promptly addressed, making it an essential piece of equipment for ECT.
Choice D reason:
A blood pressure monitor is necessary for measuring the patient’s blood pressure before, during, and after the ECT procedure. Monitoring blood pressure is crucial for detecting any significant changes that could indicate cardiovascular stress or other complications. This equipment helps ensure the patient’s safety throughout the treatment.
Choice E reason:
A portable X-ray machine is not required for ECT. X-rays are used for imaging purposes, which are not part of the standard ECT procedure. The primary focus during ECT is on monitoring the patient’s neurological and cardiovascular status, making the portable X-ray machine unnecessary for this context.
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