A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

You are being unreasonable, and I will not call your doctor at this hour."

Go back to your room, and I'll try to get in touch with your doctor."

You must be very upset about something

I can't call a doctor in the middle of the night unless it's an emergency."

Answer and Explanation

The Correct Answer is C

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.

B. "Go back to your room, and I'll try to get in touch with your doctor."

This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.

C. "You must be very upset about something."

This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.

D. "I can't call a doctor in the middle of the night unless it's an emergency."

While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.

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Correct Answer is C

Explanation

A. The client will implement alternative strategies for managing anxiety.

While addressing anxiety is important for the overall well-being of the client, it may not be the highest priority in this context. The immediate physical safety of the client during alcohol withdrawal takes precedence over addressing anxiety.

B. The client will acknowledge alcohol dependence and need for treatment.

Recognizing alcohol dependence and the need for treatment is an important step, but it may not be the highest priority. It is more focused on the client's acceptance and understanding of their situation rather than addressing immediate health risks.

C. The client's withdrawal from alcohol will be managed without complications.

This is the correct answer. Managing alcohol withdrawal without complications is the highest priority goal in this scenario. Alcohol withdrawal can lead to severe physical symptoms, including seizures and delirium tremens, which can be life-threatening. Ensuring the safe and medically supervised management of withdrawal is crucial for the client's immediate well-being.

D. The client will rebuild damaged interpersonal relationships.

While repairing damaged relationships is important for the client's overall rehabilitation, it's not the highest priority in this context. Physical health and safety take precedence over addressing interpersonal issues.

A. Helping the client identify positive personality traits B. Providing for adequate hydration and rest C. Educating the client about the consequences of alcohol misuse D. Confronting the use of denial and other defense mechanisms

Correct Answer is B

Explanation

A. Helping the client identify positive personality traits.

While addressing self-esteem and positive personality traits is valuable for the client's overall well-being, it is not the immediate priority during the detoxification phase. Ensuring physiological safety comes first.

B. Providing for adequate hydration and rest.

Explanation: The detoxification process from alcohol can result in withdrawal symptoms that range from mild discomfort to severe medical complications. Adequate hydration and rest are essential during this phase to manage withdrawal symptoms and prevent potential complications such as dehydration, electrolyte imbalances, and seizures. Maintaining the client's physiological stability is of utmost importance.

C. Educating the client about the consequences of alcohol misuse.

Providing education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but it's not the primary concern during the initial detoxification phase.

D. Confronting the use of denial and other defense mechanisms.

Addressing denial and defense mechanisms is important for therapy, but it might not be the immediate priority. Physiological stabilization through hydration and rest takes precedence in the detoxification phase.

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A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

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