A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

A client diagnosed I with hypomania who is speaking loudly on the unit.

A client diagnosed with hypomania who is complaining of pain.

A client with a history of mania who is pacing in the hallway

A client diagnosed with mania who expressed active suicidal ideations

Answer and Explanation

The Correct Answer is D

A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

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Correct Answer is ["B","C","D"]

Explanation

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

A. Concrete thinking B. Agitation C. Paranoia D. Poverty of thought

Correct Answer is C

Explanation

A. Concrete thinking: Concrete thinking refers to a style of thinking that is focused on immediate and literal aspects of information. The patient's statement involves more than concrete thinking; it includes an irrational belief about the consequences of contagious bacteria, indicating a distorted perception of reality.

B. Agitation: Agitation refers to a state of restlessness or increased activity. The patient's statement does not necessarily reflect agitation but rather a specific paranoid belief about the consequences of bacteria exposure.

C. Paranoia: This is the correct answer. Paranoia involves irrational thoughts and fears of being harmed or persecuted by others. The patient's belief that contagious bacteria are everywhere and will lead to being locked up with other infected people is indicative of paranoid ideation.

D. Poverty of thought: Poverty of thought is characterized by a lack of meaningful or detailed thought content. The patient's statement is not an example of poverty of thought; rather, it involves specific and elaborate content related to a paranoid belief.

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A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other Infected people. Which problem is evident?

Correct Answer is C

Explanation

A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid: benztropine (Cogentin), 1 mg prn: and zolpidem (Ambien). 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?

A withdrawn client diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy. What altered component of the nervous system should a nurse recognize as being implicated in this behavior?

A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?

A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?

During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior?

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse. Where do the voices come from? Which is the appropriate nursing reply?

A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis