The following statement best describes which phase in the cycle of battering: "The woman senses that the man's tolerance for frustration is declining. He becomes angry with little provocation but may be quick to apologize. She may just try to stay out of his way." The nurse recognizes this statement to be which of the following phases?

Phase IV.

Phase I.

Phase III.

Phase I.

Answer and Explanation

The Correct Answer is B

The correct answer is Choice B.

Choice A rationale: Phase IV is not a recognized phase in the cycle of battering. Typically, the cycle of battering consists of three phases: tension-building, acute battering, and honeymoon phase. Each phase has distinct characteristics.

Choice B rationale: Phase I, the tension-building phase, is characterized by increased tension, irritability, and frustration in the abuser. The victim may sense the abuser's declining tolerance for frustration, leading them to try to avoid confrontation by staying out of the abuser's way.

Choice C rationale: Phase III is the honeymoon phase, where the abuser may apologize, show remorse, and be affectionate. The victim may feel hopeful for change. However, this does not match the described behavior of increasing frustration and anger with quick apologies.

Choice D rationale: This is a duplicate of Choice B. As previously stated, Phase I, the tension-building phase, involves the buildup of tension and irritability in the abuser, leading the victim to try to stay out of the abuser's way to avoid conflict.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Monitoring vital signs throughout the day is essential for a client experiencing mania, but it is not a specific intervention related to managing the manic state. Mania is associated with high energy levels and hyperactivity, which can affect vital signs. However, this intervention does not directly address the core symptoms of mania.

Choice B rationale:

Maintaining an environment with low stimuli is crucial for managing a client experiencing mania. Manic individuals are often highly sensitive to external stimuli, and a low-stimulation environment helps reduce agitation and potential exacerbation of manic behaviors.

Choice C rationale:

Discouraging the client from taking a nap during the day is not a suitable intervention for managing mania. Sleep disturbances are common during manic episodes, and attempting to restrict daytime naps might increase restlessness and agitation.

Choice D rationale:

Weighing the client every 3 to 4 days is not a specific intervention for managing mania. Weight monitoring might be relevant in certain contexts, such as if the client's medication regimen is associated with weight changes, but it does not directly address the manifestations of mania.

Choice E rationale:

Offering nutritional foods to the client every 2 hours is an important intervention for managing mania. Manic individuals often engage in impulsive behaviors, including neglecting self-care such as eating. Providing regular and nutritious meals helps stabilize blood sugar levels and supports the body's energy demands during this hyperactive phase.

A. Ask the client direct questions about the hallucination. B. Act to the client as if the hallucination is real. C. Tell the client to go to their room and they should go away. D. Instruct the client to argue with the voices that are a part of the hallucination.

Correct Answer is A

Explanation

The correct answer is choice A. Ask the client direct questions about the hallucination.

Choice A rationale:

Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.

Choice B rationale:

Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.

Choice C rationale:

Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.

Choice D rationale:

Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan?

Correct Answer is ["B","E"]

Explanation

A nurse is caring for a client diagnosed with schizophrenia and is experiencing hallucinations. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?

A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find that I have cancer." Which of the following should be the appropriate response by the nurse?

A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

A charge nurse is preparing an educational session about addictive disorders for the nursing staff. Which of the following should the nurse include as etiological factors of addictive disorders? (Select all that apply).

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?