After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Instruct the client to reduce the volume of his voice.

Accompany the client to a quiet area of the unit.

Encourage the client to attend a support group.

Administer a PRN sedative by injection.

Answer and Explanation

The Correct Answer is B

A.   Instructing the client to reduce the volume of his voice may not be effective during a manic episode and could escalate the situation.
B.   Accompanying the client to a quiet area of the unit provides a more supportive and calming environment, allowing the client to deescalate.
C. Encouraging the client to attend a support group is a positive intervention but may not be immediately effective during an agitated state.
D.   Administering a PRN sedative by injection may be considered, but less restrictive interventions should be attempted first to promote a therapeutic environment.

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Correct Answer is C

Explanation

A. Inquiring about recent stresses is relevant but may not specifically address the emotional state associated with depression.
B. Asking about food preferences is important for a comprehensive assessment but may not be the most direct question for assessing depression.
C. Inquiring about whether the client often feels sad is crucial for assessing the emotional aspect of depression.
D. While changes in sleep patterns are significant, the question about feeling sad directly addresses the emotional component of depression, which is important for a comprehensive assessment.

A. Usual level of activity and average sleep pattern. B. Blood pressure when sitting and standing. C. Dentures to determine if they are poorly fitted. D. Body weight over the past three months.

Correct Answer is C

Explanation

A. Assessing the usual level of activity and average sleep pattern is relevant but does not directly address the observed symptoms related to speech and tongue movements.
B. Blood pressure assessment is important for overall health monitoring but is not the most immediate concern related to the observed speech and tongue abnormalities.
C. Assessing the fit of dentures is crucial in this context, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities.
D. Body weight assessment is important for overall health but is not the most immediate concern in this situation. Assessing denture fit addresses the observed speech and tongue abnormalities more directly.

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After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Correct Answer is C

Explanation

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

Correct Answer is C

Explanation

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

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