The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.

Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.

Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.

Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.

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Correct Answer is D

Explanation

Choice A rationale:
While it's important for the client to be aware of the signs and symptoms of their illness, medication monitoring is a more immediate concern.
Choice B rationale:
Participating in therapy can be beneficial, but it's not the most critical information to provide in this context.
Choice C rationale:
Living away from home is possible for many individuals with bipolar disorder, but medication management is a higher priority.
Choice D rationale:
Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity in individuals taking lithium carbonate for bipolar disorder.

A. Five-pound (2.3 kg) weight gain. B. Nausea and vomiting. C. Short-term memory loss. D. Depressed affect.

Correct Answer is B

Explanation

Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known.Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.

Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.

Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

Correct Answer is B

Explanation

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

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