The nurse is assisting in the care of a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. When collecting data, the nurse should identify that which of the following is characteristic of the client's manifestations?

Depression

Delusions

Hallucinations

Mania

Answer and Explanation

The Correct Answer is D

A. Depression. Depression is typically characterized by low energy, feelings of sadness, and withdrawal from activities. Hyperactivity and pacing are not consistent with depressive symptoms, as individuals with depression often exhibit psychomotor retardation rather than excessive movement.
B. Delusions. Delusions are fixed, false beliefs that are not based on reality, such as paranoia or grandiosity. While delusions can occur in mania, the client's primary symptoms of hyperactivity, pacing, and poor concentration are more indicative of a manic episode rather than delusional thinking alone.
C. Hallucinations. Hallucinations involve sensory perceptions that occur without external stimuli, such as hearing voices or seeing things that are not there. The client’s symptoms do not indicate hallucinations but rather heightened activity levels and distractibility.
D. Mania. Mania is characterized by hyperactivity, excessive energy, rapid speech, and poor concentration. Pacing and an inability to focus during group therapy suggest an elevated mood state, making mania the most appropriate identification of the client’s manifestations.

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

Explanation

A. Nylon socks. Nylon socks do not pose a significant risk for self-harm and can be safely kept with the client. They are not considered a ligature risk or a hazardous object.
B. Cotton underwear. Cotton underwear is not a safety concern in a mental health unit. It does not present a strangulation risk or any other immediate danger.
C. Lace-up tennis shoes. Lace-up shoes contain long laces that could be used as a ligature, posing a strangulation risk. Clients in a mental health unit are typically provided with slip-on or Velcro shoes to enhance safety.
D. Glass-framed picture of the client's partner. A glass frame poses a significant risk as it can be broken and used as a sharp object for self-harm. The nurse should ask the partner to take it home or provide a safer alternative, such as a laminated photo.
E. Necklace. A necklace can be used for strangulation, making it unsafe for a client at risk of self-harm. Removing items that could be used for ligature or harm is essential in suicide prevention.

A. Exhaustion phase B. Alarm phase C. Resistance phase D. Adaptive phase

Correct Answer is C

Explanation

A. Exhaustion phase. The exhaustion phase occurs when the body's ability to cope with stress is depleted, leading to physical and psychological impairments such as fatigue, burnout, and increased susceptibility to illness. This phase does not align with maintaining performance over an extended period.
B. Alarm phase. The alarm phase is the initial reaction to stress, activating the sympathetic nervous system and triggering the "fight-or-flight" response. While it provides a short-term boost in alertness and energy, it is not sustainable for weeks to months without impairment.
C. Resistance phase. The resistance phase allows the body to adapt to prolonged stress, maintaining homeostasis and function without significant observable impairment. During this phase, the individual continues to perform duties effectively despite ongoing stress.
D. Adaptive phase. The General Adaptation Syndrome does not include an "adaptive phase." Adaptation occurs within the resistance phase, making this answer incorrect.

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The nurse is assisting in the care of a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. When collecting data, the nurse should identify that which of the following is characteristic of the client's manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner take back home? (Select All that Apply.)

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

Explanation

Which of the following phases of Selye's General Adaptation Syndrome (GAS) reflects a nurse's ability to successfully perform duties during a prolonged period of stress lasting weeks to months without any indication of observable impairment?

Correct Answer is C

Explanation

A nurse is caring for a client who has sleep dysregulation, poor memory, and poor concentration. When collecting data, which of the following neurotransmitters should the nurse identify as being responsible for the client's manifestations?

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A nurse is collecting data from a client who has paranoid personality disorder. Which of the following findings should the nurse expect?

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

A nurse is reinforcing education to a group of clients about the process of neurotransmission. Which of the following statements about neurotransmission should the nurse make?

A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following should the nurse include in the interview to invite the client to clarify feelings?