The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

A 16-year-old client diagnosed with major depression who refuses to participate in group.

A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.

An 18-year-old client with antisocial behavior who is being yelled at by other clients.

A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

None

Answer and Explanation

The Correct Answer is B

Choice A reason: A 16-year-old client diagnosed with major depression who refuses to participate in group does not require the nurse's immediate attention. Depression is a mood disorder that causes persistent feelings of sadness, hopelessness, and loss of interest. Refusing to participate in group may indicate low motivation, social withdrawal, or poor self-esteem, which are common symptoms of depression. The nurse should respect the client's preference and offer alternative activities or individual therapy.

Choice B reason: This client requires immediate intervention because pacing can be a sign of agitation, restlessness, or escalating mania. Clients with bipolar disorder in a manic phase may exhibit increased energy, impulsivity, irritability, and even aggression. If not addressed promptly, this behavior could escalate to disruptive outbursts, impulsive actions, or even violence toward themselves or others. The nurse should intervene by using calm communication, redirection, and possibly medication if prescribed to help de-escalate the situation and ensure safety.

Choice C reason: This scenario involves peer conflict, which is important to address, but it does not necessarily indicate an immediate risk of harm. Clients with antisocial behavior often engage in conflict due to manipulative or confrontational tendencies, but being yelled at does not mean they are in immediate danger. The nurse should monitor the situation and intervene to prevent escalation, but other safety concerns take priority.

Choice D reason: A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack does not require the nurse's immediate attention. Anorexia nervosa is an eating disorder that causes extreme restriction of food intake and fear of weight gain. Refusing to eat the evening snack may indicate distorted body image, dietary rules, or anxiety, which are common factors of anorexia nervosa. The nurse should encourage the client to eat and provide support and education.

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Correct Answer is C

Explanation

Choice A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.

Choice B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.

Choice C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.

Choice D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.

A. Explain to the client that the dosage has been changed. B. Withhold the medication until the dosage can be confirmed. C. Inform him that he may refuse the medication and document whether or not he takes it. D. Tell him to take the medication then verify the dosage at the next healthcare team meeting.

Correct Answer is B

Explanation

Choice A reason: Explaining to the client that the dosage has been changed is not a safe action because it may not be true. The nurse should not assume that the prescribed dosage is correct or different from the previous one without verifying it with the healthcare provider or the medication record.

Choice C reason: Informing him that he may refuse the medication and documenting whether or not he takes it is not a responsible action because it does not address the issue of dosage discrepancy. The nurse should respect the client's right to refuse medication, but should also educate him about the benefits and risks of taking or not taking it. The nurse should also try to resolve any barriers or concerns that may affect the client's adherence to medication.

Choice D reason: Telling him to take the medication then verifying the dosage at the next healthcare team meeting is not a timely action because it may cause harm or complications to the client. The nurse should not administer any medication without checking its accuracy and appropriateness for the client. The nurse should also report and document any medication incidents as soon as possible.

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The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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