The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.
Give concise and firm directions for hygiene and dressing.
Engage the client in competitive activities.
Assign the client to a single room.
Invite the client for a walk when client's energy is high.
Provide television programs with suspense to keep attention
Correct Answer : A,C,D
Choice A rationale: Giving concise and firm directions for hygiene and dressing helps provide structure and support during periods of manic behavior.
Choice B rationale: Engaging the client in competitive activities may exacerbate manic symptoms, so it is not the best approach.
Choice C rationale: Assigning the client to a single room provides a quieter and less stimulating environment, promoting a more controlled and therapeutic setting. Choice D rationale: Inviting the client for a walk when their energy is high allows for a structured outlet for excess energy and may help with symptom management.
Choice E rationale: Providing television programs with suspense may contribute to overstimulation and is not the best approach during manic episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Demonstrates thought-blocking is incorrect. Thought-blocking involves a sudden interruption in the client's speech, whereas the client in this scenario is experiencing racing thoughts.
Choice B rationale: Exhibits tangential thinking is the correct description. Tangential thinking involves presenting numerous ideas that are loosely or not at all connected. The client's statements reflect tangential thinking as she jumps from one idea to another without clear connections.
Choice C rationale: Displays the use of word salad is incorrect. Word salad refers to a mix of words and phrases that lack coherence and do not form a meaningful statement. The client's statements, though rapid, are connected and form a series of thoughts. Choice D rationale: Uses incoherent speech is incorrect. Incoherent speech implies a lack of clarity and organization in the client's verbal expression. The client's statements, while fast-paced, maintain coherence and are comprehensible.
Correct Answer is B
Explanation
Choice A rationale: While frustration may contribute to distress, the client's recent life events, such as a breakup and job loss, suggest a stronger link to a sense of loss.
Choice B rationale: Experiencing a divorce, job loss, and recent breakup are significant life events that contribute to a profound sense of loss, which can lead to feelings of depression.
Choice C rationale: Poor self-esteem can contribute to depression, but the client's recent life events are more directly related to the current feelings of depression.
Choice D rationale: While a lack of intimate relationships can impact mental health, the recent breakup is a more immediate factor contributing to the client's depression.
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