Rationale: A client with bipolar disorder, manic episode, typically exhibits increased energy and activity level, along with other symptoms such as euphoria, grandiosity, impulsivity, distractibility, and pressured speech.

Incorrect options:

A) Decreased appetite and weight loss - These are more likely to be seen in a client with bipolar disorder, depressive episode, or another mood disorder such as major depressive disorder.

C) Social withdrawal and isolation - These are also more indicative of a depressive episode or another mood disorder that affects the client's interest and motivation to interact with others.

D) Low self-esteem and hopelessness - These are signs of negative self-evaluation and pessimism that are common in depressive disorders, not manic episodes.

Correct answer: B) Obtain informed consent from the client or a legal guardian

Rationale: ECT is an invasive procedure that involves inducing a seizure in the brain using electrical currents. It has potential risks and benefits that the client or a legal guardian must be informed of before giving consent. The nurse has a responsibility to ensure that the consent is obtained and documented.

Incorrect options:

A) Administer a muscle relaxant and an anesthetic agent - This is not a nursing intervention, but a medical intervention that is performed by the anesthesiologist or another qualified provider.

C) Monitor the client's vital signs and oxygen saturation - This is an important nursing intervention during and after ECT, but not before. The nurse should monitor the client for any changes in blood pressure, heart rate, rhythm, and oxygenation during the procedure and recovery.

D) Ensure that the client has an empty stomach and bladder - This is a necessary precaution to prevent aspiration and urinary incontinence during ECT, but it is not the most important nursing intervention before ECT.

Correct answer: D) Validate the client's feelings and perceptions without reinforcing the hallucinations

Rationale: The nurse should acknowledge the client's feelings and perceptions without agreeing or disagreeing with the content of the hallucinations. This helps to establish trust and rapport with the client, as well as reduce anxiety and fear. The nurse should also help the client identify triggers and coping strategies for managing the hallucinations.

Incorrect options:

A) Ask the client to describe the content and tone of the hallucinations - This may increase the client's attention and response to the hallucinations, as well as reinforce their reality. The nurse should avoid focusing on the details of the hallucinations unless they pose a risk of harm to self or others.

B) Tell the client to ignore the hallucinations and focus on reality - This may invalidate the client's experience and make them feel misunderstood or rejected. The nurse should not dismiss or challenge the client's hallucinations, as this may increase their defensiveness and resistance.

C) Distract the client with music, games, or other activities - This may be helpful in some situations, but it is not a therapeutic communication technique. The nurse should not use distraction as a substitute for addressing the underlying issues or exploring the meaning of the hallucinations.

Correct answer: D) All of the above

Rationale: The nurse should use a combination of strategies to facilitate the client's participation in the group therapy session. Asking open-ended questions can help the client express their opinions and perspectives, as well as stimulate the group dialogue. Using silence can provide the client with a safe and nonjudgmental space to reflect and communicate at their own pace. Giving positive feedback to other clients can reinforce their engagement and motivation, as well as model appropriate social skills and behaviors for the quiet client.

Correct answer: B) Face the client directly and maintain eye contact.

Rationale: The nurse should face the client directly and maintain eye contact when communicating with a client who has a hearing impairment, as this allows the client to read the nurse's lips and observe nonverbal cues. The nurse should also speak clearly and at a normal pace, and avoid covering the mouth or chewing gum.

Incorrect options:

A) Speak loudly and slowly. - This is an incorrect action, as speaking loudly and slowly can distort the sound and make it harder for the client to understand. It can also be perceived as patronizing or disrespectful by the client.

C) Use gestures and facial expressions to emphasize key points. - This is an incorrect action, as gestures and facial expressions can be ambiguous or misleading, and may not convey the intended message. The nurse should use simple and concrete language, and avoid using idioms, slang, or jargon.

D) Repeat the same information using different words if the client does not understand. - This is an incorrect action, as repeating the same information using different words can confuse the client and increase frustration. The nurse should ask the client to repeat back what they understood, and clarify any misunderstandings.

Correct answer: B) Use a professional interpreter if available.

Rationale: The nurse should use a professional interpreter if available when communicating with a client who speaks a different language or has limited English proficiency, as this ensures accurate and culturally sensitive communication. The interpreter should be trained in medical terminology and confidentiality, and should not be a family member or friend of the client.

Incorrect options:

A) Ask the client to speak slower and louder. - This is an incorrect action, as asking the client to speak slower and louder can be perceived as rude or disrespectful by the client. It can also increase anxiety and stress for both parties, and impair communication.

C) Avoid asking questions that require more than a yes or no answer. - This is an incorrect action, as avoiding questions that require more than a yes or no answer can limit the amount of information obtained from the client, and prevent the nurse from assessing the client's needs, preferences, and concerns. The nurse should ask open-ended questions that encourage elaboration, clarification, and feedback from the client.

D) Assume that the client understands everything the nurse says. - This is an incorrect action, as assuming that the client understands everything the nurse says can lead to miscommunication, errors, and adverse outcomes. The nurse should verify the client's understanding by asking them to repeat back or demonstrate what they learned, and provide written materials in their preferred language if possible.

Correct answer: C) "What are some of the challenges you face in managing your diabetes?"

Rationale: The nurse demonstrates effective communication by asking the client what are some of

the challenges they face in managing their diabetes, as this shows empathy, respect, and interest in

the client's perspective. It also allows the nurse to identify any barriers or difficulties that may affect

the client's adherence to self-care measures, and provide appropriate support and resources.

Incorrect options:

A) "Do you have any questions about what I just told you?" - This is an ineffective statement,

as it implies that the nurse expects the client to have questions, which may discourage them from

asking or expressing their concerns. It also puts the burden of communication on the client, rather

than on the nurse. A better way to phrase this question is "What questions do you have about what

I just told you?"

B) "How do you feel about managing your diabetes at home?" - This is an ineffective statement,

as it is too vague and broad, and may not elicit specific or useful information from the client. It also

focuses on the client's feelings, rather than on their knowledge, skills, and behaviors. A better way to

phrase this question is "How confident are you in managing your diabetes at home?"

D) "You need to follow these instructions carefully to avoid complications." - This is an ineffective

statement, as it is authoritative and paternalistic, and may undermine the client's autonomy and

motivation. It also focuses on the negative consequences of non-adherence, rather than on the positive

benefits of adherence. A better way to phrase this statement is "Following these instructions will help

you control your blood glucose and prevent complications."

Correct answer: D) All of the above.

Rationale: The nurse should take all of the above actions to communicate effectively with the family

members of a client who has terminal cancer and is receiving palliative care, as this demonstrates

respect, empathy, and compassion. The nurse should provide factual information about the client's

condition and prognosis, using clear and simple language, and avoiding false reassurance or giving

unrealistic hope. The nurse should encourage the family members to express their emotions and offer

support, using active listening skills, such as nodding, paraphrasing, reflecting, and summarizing. The

nurse should also suggest coping strategies and resources for the family members to deal with their

grief, such as counseling, support groups, spiritual care, or hospice services.

Incorrect options:

None.

Correct answer: A) "Do you take your blood pressure medication as prescribed?"

Rationale: The nurse asks a closed-ended question when they ask the client if they take their blood

pressure medication as prescribed, as this question can be answered with a yes or no response. Closed-

ended questions are useful for obtaining specific or factual information from the client, but they can also

limit communication and rapport.

Incorrect options:

B) "What are some of the foods that you eat on a regular basis?" - This is an example of an open-

ended question, as this question cannot be answered with a yes or no response. Open-ended questions

are useful for obtaining more detailed or descriptive information from the client, and for encouraging

communication and rapport.

C) "How often do you exercise and what type of exercise do you do?" - This is an example of an open-

ended question, as this question cannot be answered with a yes or no response. Open-ended questions

are useful for obtaining more detailed or descriptive information from the client, and for encouraging

communication and rapport.

D) "How do you cope with stress in your life?" - This is an example of an open-ended question,

as this question cannot be answered with a yes or no response. Open-ended questions are useful for

obtaining more detailed or descriptive information from the client, and for encouraging communication

and rapport.

Correct answer: C) Use visual aids and demonstrations to illustrate key points.

Rationale: The nurse should use visual aids and demonstrations to illustrate key points when providing discharge instructions to a client who has COPD, as this enhances communication and learning by appealing to different learning styles, reinforcing verbal information, and making complex concepts more understandable. Visual aids and demonstrations can include diagrams, pictures, models, or videos that help the client visualize proper breathing techniques, use of oxygen therapy, medication administration, smoking cessation strategies, healthy nutrition choices, and infection prevention measures.

Incorrect options:

A) Use medical terminology and abbreviations to explain complex concepts. - This is not an effective technique, as using medical terminology and abbreviations can confuse the client and hinder their understanding. The nurse should use simple and clear language, avoiding jargon and technical terms, to ensure the client comprehends the information.

B) Provide all the information at once to avoid overwhelming the client. - Providing all the information at once can overwhelm the client and make it difficult for them to retain and understand the instructions. It is better to break down the information into manageable chunks and provide it in a step-by-step manner to promote comprehension and learning.

D) Ask closed-ended questions to assess the client's understanding. - Closed-ended questions that can be answered with "yes" or "no" may not provide a comprehensive assessment of the client's understanding. Open-ended questions that encourage the client to express their understanding and ask for clarification or elaboration are more effective in assessing comprehension and facilitating communication.

Correct answer: D) All of the above.

Rationale: Low self-esteem is a negative evaluation of one's self-worth, often associated with depression. Clients with low self-esteem may exhibit behaviors such as making negative statements about themselves, expressing dissatisfaction with their appearance and abilities, avoiding eye contact and speaking in a low voice, and having difficulty accepting compliments or praise.

Incorrect options:

A) The client frequently makes negative statements about themselves. - This is a correct indicator of low self-esteem, but not the only one.

B) The client expresses dissatisfaction with their appearance and abilities. - This is a correct indicator of low self-esteem, but not the only one.

C) The client avoids eye contact and speaks in a low voice. - This is a correct indicator of low self-esteem, but not the only one.

Correct answer: D) All of the above.

Rationale: Group therapy is a form of psychotherapy that involves one or more therapists working with several clients who share a common problem or goal. Group therapy can help clients with anxiety disorders by providing social support, education, coping skills, and exposure to feared situations. To facilitate effective communication and interaction among the group members, the nurse should use strategies such as establishing clear and consistent rules and expectations for the group, encouraging active participation and feedback from all group members, and using open-ended questions and reflective statements to elicit responses.

Incorrect options:

A) Establish clear and consistent rules and expectations for the group. - This is a correct strategy, but not the only one.

B) Encourage active participation and feedback from all group members. - This is a correct strategy, but not the only one.

C) Use open-ended questions and reflective statements to elicit responses. - This is a correct strategy, but not the only one.

Correct answer: D) "That must be very frightening for you. How can I help you feel safe?"

Rationale: Hallucinations are sensory perceptions that occur without external stimuli, often associated with schizophrenia. Clients who experience auditory hallucinations may hear voices that are threatening, derogatory, or commanding. The nurse should respond to the client's hallucinations with empathy, respect, and validation, while also assessing their risk for self-harm or harm to others. The nurse should also help the client cope with their hallucinations by providing distraction, reality orientation, medication administration, and environmental modification.

Incorrect options:

A) "Do you have a plan to harm yourself?" - This is an important question to ask when assessing suicide risk, but it does not address the client's hallucinations or provide any support or reassurance.

B) "The voices are not real and they cannot hurt you." - This is an invalidating response that contradicts the client's reality and may cause them to feel defensive or distrustful of the nurse.

C) "I don't hear any voices. What are they saying to you?" - This is a curious response that may reinforce the client's hallucinations or increase their anxiety.

Correct answer: D) All of the above.

Rationale: Autonomy is the ability to act independently and make choices based on one's own values and beliefs. Respect for autonomy is an ethical principle that guides the nurse-client relationship, especially in mental health settings. The nurse should demonstrate respect for the client's autonomy by informing the client about their diagnosis and treatment options, asking the client for their preferences and opinions regarding their care, and encouraging the client to participate in decision-making and goal-setting.

Incorrect options:

A) The nurse informs the client about their diagnosis and treatment options. - This is a correct action, but not the only one.

B) The nurse asks the client for their preferences and opinions regarding their care. - This is a correct action, but not the only one.

C) The nurse encourages the client to participate in decision-making and goal-setting. - This is a correct action, but not the only one.

Correct answer: A) "How do you feel today?"

Rationale: Mood is the subjective emotional state that the client experiences and reports. Mood can be assessed by asking the client how they feel today, or by using standardized scales such as the Hamilton Rating Scale for Depression or the Patient Health Questionnaire-9. Mood can be described using terms such as happy, sad, angry, anxious, or indifferent.

Incorrect options:

B) "How would you rate your energy level on a scale of 1 to 10?" - This is a question that assesses the client's physical functioning, not their mood.

C) "Do you have any thoughts of harming yourself or others?" - This is a question that assesses the client's suicidal or homicidal ideation, not their mood.

D) "How well are you able to concentrate and remember things?" - This is a question that assesses the client's cognitive functioning, not their mood.

Correct answer: D) All of the above.

Rationale: Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI) that is used to treat OCD and other anxiety disorders. SSRIs work by increasing the availability of serotonin in the brain, which helps regulate mood, anxiety, and compulsive behaviors. The nurse should include the following information in the teaching:

- The medication should be taken with food to prevent stomach upset, nausea, or vomiting.

- The medication should not be taken with alcohol, as this can increase the risk of adverse effects such as drowsiness, dizziness, or liver damage.

- The medication may cause sexual dysfunction as a side effect, such as decreased libido, erectile dysfunction, or delayed ejaculation. The client should report any changes in sexual function to their provider.

Incorrect options:

A) "You should take this medication with food to prevent stomach upset." - This is a correct information, but not the only one.

B) "You should avoid drinking alcohol while taking this medication." - This is a correct information, but not the only one.

C) "You may experience sexual dysfunction as a side effect of this medication." - This is a correct information, but not the only one.

Correct answer: B) Teach the client relaxation techniques such as deep breathing or progressive muscle relaxation.

Rationale: Flashbacks are vivid and intrusive recollections of a traumatic event that occur involuntarily and cause distress to the client. Flashbacks can be triggered by reminders of the trauma, such as sights, sounds, smells, or emotions. The nurse should help the client cope with flashbacks by teaching them relaxation techniques such as deep breathing or progressive muscle relaxation, which can help reduce anxiety and physiological arousal. The nurse should also stay with the client until they are calm and oriented.

Incorrect options:

A) Ask the client to describe the details of the traumatic event. - This is an inappropriate intervention that may worsen the client's distress and retraumatize them. It is important for the nurse to respect the client's boundaries and avoid pressuring them to discuss or relive the traumatic event unless the client initiates the conversation and feels comfortable doing so.

C) Remind the client that they are safe and that the flashbacks are not real. - While it is important to reassure the client that they are safe, simply reminding them that the flashbacks are not real may not be sufficient to alleviate their distress. Flashbacks can be very real and overwhelming for individuals with PTSD, and dismissing their experiences may invalidate their feelings. Instead, the nurse should focus on providing support, validation, and coping strategies such as relaxation techniques to help the client manage and reduce the intensity of their flashbacks.

D) All of the above. - This is an incorrect option, as asking the client to describe the details of the traumatic event and reminding them that the flashbacks are not real are not appropriate interventions for coping with flashbacks in clients with PTSD. Teaching relaxation techniques, however, is an effective and appropriate intervention for managing and coping with flashbacks.

Correct answer: B) Use gestures and pictures to supplement verbal communication.

Rationale: The nurse should use nonverbal communication methods, such as gestures, pictures, or writing, to supplement verbal communication and enhance the client's comprehension. These methods can also help the client express their needs and preferences.

Incorrect options:

A) Speak loudly and slowly to the client. - This is not an appropriate strategy, as speaking loudly can be perceived as shouting or anger, and speaking slowly can be patronizing or insulting. The nurse should speak clearly and at a normal pace, using simple and familiar words.

C) Ask the client yes or no questions only. - This is not an optimal strategy, as it limits the client's ability to communicate their feelings, thoughts, and concerns. The nurse should ask open-ended questions whenever possible, and allow the client time to respond.

D) Avoid eye contact with the client to reduce anxiety. - This is not a helpful strategy, as eye contact is an important aspect of communication that conveys interest, respect, and empathy. The nurse should maintain eye contact with the client, unless it is culturally inappropriate.

Correct answer: A) Use a professional interpreter to assist with the communication.

Rationale: The nurse should use a professional interpreter who is trained and qualified in medical terminology and cultural sensitivity to assist with the communication between the nurse and the client. This ensures that the information is conveyed accurately and respectfully, and that the client's privacy and confidentiality are maintained.

Incorrect options:

B) Ask a family member or friend of the client to act as an interpreter. - This is not a recommended practice, as family members or friends may not be fluent in both languages, may not understand medical terms, may omit or add information, or may have biases or emotional involvement that affect the communication.

C) Repeat the questions several times until the client understands. - This is not an effective strategy, as repeating the same words may not improve comprehension, and may frustrate or offend the client. The nurse should rephrase or simplify the questions, or use nonverbal cues such as gestures or pictures, to facilitate understanding.

D) Use medical jargon and technical terms to explain the diagnosis and treatment. - This is not an appropriate strategy, as medical jargon and technical terms may confuse or intimidate the client, especially if they have limited English proficiency. The nurse should use plain language and avoid acronyms, abbreviations, or slang when communicating with the client.

Correct answer: A) "I see. And how long have you been experiencing these symptoms?"

Rationale: The nurse demonstrates active listening skills by using verbal prompts such as "I see" to acknowledge the client's message, and by asking open-ended questions such as "how long" to elicit more information and clarify details.

Incorrect options:

B) "That sounds very stressful. You must be feeling overwhelmed." - This statement does not demonstrate active listening skills, as it assumes how the client feels without checking for accuracy. The nurse should avoid making assumptions or judgments about the client's feelings, and instead ask them how they feel or reflect their emotions back to them.

C) "I understand what you are going through. I had a similar problem last year." - This statement does not demonstrate active listening skills, as it shifts the focus from the client to the nurse's personal experience. The nurse should avoid self-disclosure or comparisons that may minimize or invalidate the client's situation.

D) "Let me tell you what you need to do to improve your health." - This statement does not demonstrate active listening skills, as it implies that the nurse knows better than the client what is best for them. The nurse should avoid giving advice or directives that may undermine the client's autonomy or motivation.

Correct answer: A) Autonomy

Rationale: The nurse is demonstrating the ethical principle of autonomy, which means respecting the client's right to make their own decisions about their health care, and honoring their preferences, values, and beliefs.

Incorrect options:

B) Beneficence - This is the ethical principle of doing good or acting in the best interest of the client, which may or may not align with the client's wishes or choices.

C) Justice - This is the ethical principle of treating all clients fairly and equitably, and distributing resources and services based on need and availability.

D) Fidelity - This is the ethical principle of being faithful or loyal to the client, and keeping one's promises and commitments.

Correct answer: A) Autonomy

Rationale: The nurse is demonstrating the ethical principle of autonomy, which means respecting the client's right to make their own decisions about their health care, and honoring their preferences, values, and beliefs.

Incorrect options:

B) Beneficence - This is the ethical principle of doing good or acting in the best interest of the client, which may or may not align with the client's wishes or choices.

C) Justice - This is the ethical principle of treating all clients fairly and equitably, and distributing resources and services based on need and availability.

D) Fidelity - This is the ethical principle of being faithful or loyal to the client, and keeping one's promises and commitments.

Correct answer: C) Face the client and speak slowly and clearly.

Rationale: The nurse should face the client and speak slowly and clearly, using simple and familiar words, to enhance understanding. The nurse should also maintain eye contact, use facial expressions and gestures, and check for comprehension frequently.

Incorrect options:

A) Speak in a high-pitched voice to increase clarity. - This is not a helpful technique, as a high-pitched voice may be more difficult to hear or understand than a normal or low-pitched voice. The nurse should speak in a normal or slightly lower tone of voice, and avoid shouting or whispering.

B) Stand behind the client and speak into their ear. - This is not an effective technique, as standing behind the client prevents them from seeing the nurse's face and lips, which can aid in communication. The nurse should stand in front of the client, at their eye level, and speak into their better ear if they have one.

D) Cover the mouth with a hand while speaking to reduce background noise. - This is not an appropriate technique, as covering the mouth with a hand obscures the nurse's lips and facial expressions, which can hinder communication. The nurse should avoid covering their mouth or wearing a mask if possible, and reduce background noise by closing doors or windows, turning off radios or televisions, or moving to a quieter location.

Correct answer: D) "I'm sorry you're feeling sad. Can you tell me more about it?"

Rationale: The nurse indicates an understanding of therapeutic communication by expressing empathy for the client's emotion, and by inviting them to share more information using an open-ended question.

Incorrect options:

A) "Do you remember what we talked about yesterday?" - This statement does not indicate an understanding of therapeutic communication, as it tests the client's memory, which may be impaired due to dementia. The nurse should avoid asking questions that rely on recall, and instead provide cues or reminders of previous conversations.

B) "Why are you so agitated today? What's wrong with you?" - This statement does not indicate an understanding of therapeutic communication, as it implies that there is something wrong with the client, and may sound accusatory or judgmental. The nurse should avoid asking "why" questions that may put the client on the defensive, and instead use "what" or "how" questions that explore the client's feelings or needs.

C) "You seem confused. Let me explain everything to you again." - This statement does not indicate an understanding of therapeutic communication, as it labels the client as confused, which may be demeaning or discouraging. The nurse should avoid using negative labels or terms that may affect the client's self-esteem or confidence.

Correct answer: C) Log out of the system after completing the documentation.

Rationale: The nurse should log out of the system after completing the documentation, as this prevents unauthorized access to the client's information by other users. Logging out also ensures that the nurse's name and time stamp are accurate for each entry.

Incorrect options:

A) Use a personal identification number (PIN) to access the system. - This is a correct action, but not the best answer, as using a PIN alone does not ensure confidentiality and security of the client's information. The nurse should also log out of the system after completing the documentation.

B) Share the PIN with another nurse who needs to update the record. - This is an incorrect action, as sharing the PIN with another nurse violates the client's privacy and compromises the security of the system. The nurse should never share the PIN with anyone, and each nurse should use their own PIN to access and document in the record.

D) Leave the computer screen on while attending to another client. - This is an incorrect action, as leaving the computer screen on while attending to another client exposes the client's information to anyone who can view the screen. The nurse should log out of the system or lock the screen before leaving the computer.

Correct answer: B) Use gestures and pictures to supplement verbal communication.

Rationale: The nurse should use gestures and pictures to supplement verbal communication, as this helps to convey meaning and clarify messages for clients who have difficulty understanding or producing speech due to aphasia. Gestures and pictures can also help to reduce frustration and anxiety for both parties.

Incorrect options:

A) Speak loudly and slowly to the client. - This is an inappropriate strategy, as speaking loudly and slowly to the client may imply that they are hard of hearing or cognitively impaired, which can be insulting and demeaning. The nurse should speak clearly and at a normal volume and pace, unless there is evidence of hearing loss or cognitive impairment.

C) Ask open-ended questions to elicit more information from the client. - This is an ineffective strategy, as asking open-ended questions may overwhelm or confuse clients who have difficulty expressing themselves due to aphasia. The nurse should ask simple, yes-or-no questions or offer choices that require minimal verbal responses from the client.

D) Finish the client's sentences when they have difficulty expressing themselves. - This is a disrespectful strategy, as finishing

the client's sentences may interrupt their thoughts or impose words that they do not intend to say. The nurse should allow adequate time for the client to communicate and encourage them to use alternative methods, such as writing or pointing, if needed.

Correct answer: D) Respect different opinions and perspectives from other team members.

Rationale: The nurse should respect different opinions and perspectives from other team members, as this fosters a culture of mutual trust, collaboration, and shared decision-making among interprofessional team members. Respecting diversity also enhances creativity and innovation in problem-solving and improves client outcomes.

Incorrect options:

A) Delegate tasks according to each team member's scope of practice and expertise. - This is a correct action, but not

the best answer, as delegating tasks according to each team member's scope of practice and expertise is only one aspect of effective teamwork. The nurse should also respect different opinions and perspectives from other team members, as this is more relevant to promoting effective teamwork than delegating tasks.

B) Communicate with other team members using abbreviations and jargon for efficiency. - This is an incorrect action, as communicating with other team members using abbreviations and jargon may lead to miscommunication, errors, or confusion among interprofessional team members who may not be familiar with the terms. The nurse should communicate with other team members using clear, concise, and standardized language for accuracy and clarity.

C) Make decisions based on evidence-based practice and best available data. - This is a correct action, but not the best answer, as making decisions based on evidence-based practice and best available data is a common goal and expectation for all interprofessional team members, not a specific action that promotes effective teamwork. The nurse should respect different opinions and perspectives from other team members, as this is more relevant to promoting effective teamwork than making decisions.

Correct answer: C) Document the DNR order in the nursing care plan and communicate it to other health care team members.

Rationale: The nurse should document the DNR order in the nursing care plan and communicate it to other health care team members, as this ensures that the client's wishes are respected and followed in the event of a cardiac or respiratory arrest. Documenting and communicating the DNR order also prevents unnecessary or unwanted interventions that may cause harm or distress to the client.

Incorrect options:

A) Review the DNR order with the client and their family to ensure their understanding and agreement. - This is an unnecessary action, as reviewing the DNR order with the client and their family implies that they may not have made an informed decision or that they may change their mind, which can be disrespectful or coercive. The nurse should assume that the client and their family have already discussed and agreed on the DNR order with the health care provider who wrote it, unless there is evidence of misunderstanding or disagreement.

B) Notify the health care provider of the DNR order and request a written confirmation. - This is an unnecessary action, as notifying

the health care provider of the DNR order and requesting a written confirmation implies that there may be a discrepancy or doubt about

the validity of the order, which can be disrespectful or suspicious. The nurse should assume that the health care provider who wrote

the DNR order has already obtained informed consent from the client and their family and has documented it appropriately, unless there is evidence of error or omission.

D) Initiate a palliative care consultation for the client and their family to discuss end-of-life care options. - This is an inappropriate action, as initiating a palliative care consultation for the client and their family implies that they have a terminal condition or a poor prognosis, which may not be true for clients with pneumonia who have a DNR order. The nurse should not assume that all clients with a DNR order need or want palliative care, unless they express an interest or a need for it.

Correct answer: D) The client's current condition, changes, interventions, and outcomes.

Rationale: The nurse should prioritize the client's current condition, changes, interventions, and outcomes when receiving

the report, as this provides essential information about the client's status, progress, response to treatment, and plan of care. This information also helps to identify any potential problems or issues that need immediate attention or follow-up.

Incorrect options:

A) The client's name, age, diagnosis, and allergies. - This is important information, but not the most important when receiving

the report, as this provides basic demographic and background information about the client that can be easily accessed from

the chart or other sources. This information does not reflect the client's current condition or needs.

B) The client's vital signs, laboratory results, and medications. - This is important information, but not the most important when receiving

the report, as this provides objective data about the client's physiological status that can be easily accessed from

the chart or other sources. This information does not reflect the client's subjective experience or response to treatment.

C) The client's goals, preferences, values, and expectations. - This is important information,

but not the most important when receiving

the report, as this provides subjective data about

the client's psychosocial status that can be easily accessed

Correct answer: C) Log out of the system after completing the documentation.

Rationale: The nurse should log out of the system after completing the documentation, as this prevents unauthorized access to the client's information by other users. Logging out also ensures that the nurse's name and time stamp are accurate for each entry.

Incorrect options:

A) Use a personal identification number (PIN) to access the system. - This is a correct action, but not the best answer, as using a PIN alone does not ensure confidentiality and security of the client's information. The nurse should also log out of the system after completing the documentation.

B) Share the PIN with another nurse who needs to update the record. - This is an incorrect action, as sharing the PIN with another nurse violates the client's privacy and compromises the security of the system. The nurse should never share the PIN with anyone, and each nurse should use their own PIN to access and document in the record.

D) Leave the computer screen on while attending to another client. - This is an incorrect action, as leaving the computer screen on while attending to another client exposes the client's information to anyone who can view the screen. The nurse should log out of the system or lock the screen before leaving the computer.

Correct answer: B) Use gestures and pictures to supplement verbal communication.

Rationale: The nurse should use gestures and pictures to supplement verbal communication, as this helps to convey meaning and clarify messages for clients who have difficulty understanding or producing speech due to aphasia. Gestures and pictures can also help to reduce frustration and anxiety for both parties.

Incorrect options:

A) Speak loudly and slowly to the client. - This is an inappropriate strategy, as speaking loudly and slowly to the client may imply that they are hard of hearing or cognitively impaired, which can be insulting and demeaning. The nurse should speak clearly and at a normal volume and pace, unless there is evidence of hearing loss or cognitive impairment.

C) Ask open-ended questions to elicit more information from the client. - This is an ineffective strategy, as asking open-ended questions may overwhelm or confuse clients who have difficulty expressing themselves due to aphasia. The nurse should ask simple, yes-or-no questions or offer choices that require minimal verbal responses from the client.

D) Finish the client's sentences when they have difficulty expressing themselves. - This is a disrespectful strategy, as finishing

the client's sentences may interrupt their thoughts or impose words that they do not intend to say. The nurse should allow adequate time for the client to communicate and encourage them to use alternative methods, such as writing or pointing, if needed.

Correct answer: D) Respect different opinions and perspectives from other team members.

Rationale: The nurse should respect different opinions and perspectives from other team members, as this fosters a culture of mutual trust, collaboration, and shared decision-making among interprofessional team members. Respecting diversity also enhances creativity and innovation in problem-solving and improves client outcomes.

Incorrect options:

A) Delegate tasks according to each team member's scope of practice and expertise. - This is a correct action, but not

the best answer, as delegating tasks according to each team member's scope of practice and expertise is only one aspect of effective teamwork. The nurse should also respect different opinions and perspectives from other team members, as this is more relevant to promoting effective teamwork than delegating tasks.

B) Communicate with other team members using abbreviations and jargon for efficiency. - This is an incorrect action, as communicating with other team members using abbreviations and jargon may lead to miscommunication, errors, or confusion among interprofessional team members who may not be familiar with the terms. The nurse should communicate with other team members using clear, concise, and standardized language for accuracy and clarity.

C) Make decisions based on evidence-based practice and best available data. - This is a correct action, but not the best answer, as making decisions based on evidence-based practice and best available data is a common goal and expectation for all interprofessional team members, not a specific action that promotes effective teamwork. The nurse should respect different opinions and perspectives from other team members, as this is more relevant to promoting effective teamwork than making decisions.

Correct answer: C) Document the DNR order in the nursing care plan and communicate it to other health care team members.

Rationale: The nurse should document the DNR order in the nursing care plan and communicate it to other health care team members, as this ensures that the client's wishes are respected and followed in the event of a cardiac or respiratory arrest. Documenting and communicating the DNR order also prevents unnecessary or unwanted interventions that may cause harm or distress to the client.

Incorrect options:

A) Review the DNR order with the client and their family to ensure their understanding and agreement. - This is an unnecessary action, as reviewing the DNR order with the client and their family implies that they may not have made an informed decision or that they may change their mind, which can be disrespectful or coercive. The nurse should assume that the client and their family have already discussed and agreed on the DNR order with the health care provider who wrote it, unless there is evidence of misunderstanding or disagreement.

B) Notify the health care provider of the DNR order and request a written confirmation. - This is an unnecessary action, as notifying

the health care provider of the DNR order and requesting a written confirmation implies that there may be a discrepancy or doubt about

the validity of the order, which can be disrespectful or suspicious. The nurse should assume that the health care provider who wrote

the DNR order has already obtained informed consent from the client and their family and has documented it appropriately, unless there is evidence of error or omission.

D) Initiate a palliative care consultation for the client and their family to discuss end-of-life care options. - This is an inappropriate action, as initiating a palliative care consultation for the client and their family implies that they have a terminal condition or a poor prognosis, which may not be true for clients with pneumonia who have a DNR order. The nurse should not assume that all clients with a DNR order need or want palliative care, unless they express an interest or a need for it.

Correct answer: D) The client's current condition, changes, interventions, and outcomes.

Rationale: The nurse should prioritize the client's current condition, changes, interventions, and outcomes when receiving

the report, as this provides essential information about the client's status, progress, response to treatment, and plan of care. This information also helps to identify any potential problems or issues that need immediate attention or follow-up.

Incorrect options:

A) The client's name, age, diagnosis, and allergies. - This is important information, but not the most important when receiving

the report, as this provides basic demographic and background information about the client that can be easily accessed from

the chart or other sources. This information does not reflect the client's current condition or needs.

B) The client's vital signs, laboratory results, and medications. - This is important information, but not the most important when receiving

the report, as this provides objective data about the client's physiological status that can be easily accessed from the chart or other sources. This information does not reflect the client's subjective experience or response to treatment.

C) The client's goals, preferences, values, and expectations. - This is important information, but not the most important when receiving the report, as this provides subjective data about the client's psychosocial status that can be easily accessed

Correct answer: A) Decreased need for sleep

Rationale: A client who is experiencing a manic episode may have a decreased need for sleep, as they feel energized, restless, and euphoric. They may also engage in multiple activities, projects, or plans without completing them.

Incorrect options:

B) Social withdrawal - This is more characteristic of a depressive episode, where the client may isolate themselves from others and lose interest in activities they previously enjoyed.

C) Slow and monotonous speech - This is also more indicative of a depressive episode, where the client may have psychomotor retardation, which affects their speech and movement.

D) Low self-esteem - This is another sign of a depressive episode, where the client may have negative thoughts about themselves, their abilities, and their worth.

Correct answer: C) "That must be very frightening for you. I am here to help you."

Rationale: The nurse should respond with empathy and support, acknowledging the client's feelings and offering assistance. The nurse should also assess the client's risk for self-harm and implement safety measures as needed.

Incorrect options:

A) "You should ignore those voices. They are not real." - This is a dismissive and invalidating response that may make the client feel misunderstood and alienated. The nurse should not challenge the client's perception of reality, as this may increase their anxiety and paranoia.

B) "What do the voices sound like? Are they familiar or unfamiliar to you?" - This is an inappropriate response that may encourage the client to focus on the voices and reinforce their delusions. The nurse should not ask questions that may stimulate the client's hallucinations or delusions, as this may worsen their symptoms.

D) "Why do you think the voices are telling you to harm yourself?" - This is a potentially harmful response that may imply that the client is responsible for their hallucinations or that there is a rational explanation for them. The nurse should not ask questions that may increase the client's guilt or confusion.

Correct answer: B) "I understand that you are upset, but this is the policy of the unit. You can see your visitors again tomorrow."

Rationale: The nurse should respond with empathy and assertiveness, acknowledging the client's feelings but also setting clear and consistent boundaries. The nurse should explain the rationale for the policy and offer reassurance that the client can see their visitors again.

Incorrect options:

A) "You have no right to talk to me like that. I am only doing my job." - This is a defensive and confrontational response that may escalate the situation and damage the therapeutic relationship. The nurse should not take the client's anger personally or react emotionally.

C) "If you continue to behave this way, I will have to call security and have them escort your visitors out." - This is a threatening and punitive response that may increase the client's fear of abandonment and provoke more hostility. The nurse should not use coercive or authoritarian tactics unless there is an imminent risk of harm.

D) "You are being manipulative and unreasonable. You need to calm down and accept the situation." - This is a judgmental and invalidating response that may make the client feel misunderstood and rejected. The nurse should not label or criticize the client's behavior or emotions.

Correct answer: C) Allow the client to express their emotions and provide support.

Rationale: The nurse should allow the client to express their emotions and provide support, as this can help the client process their trauma and cope with their feelings. The nurse should also acknowledge the client's courage and strength for sharing their story and thank them for their contribution to the group.

Incorrect options:

A) Ask the client to stop crying and focus on their breathing. - This is a dismissive and insensitive response that may make the client feel ashamed or embarrassed for crying. The nurse should not try to suppress or minimize the client's emotions, as this can hinder their healing process.

B) Encourage the other group members to comfort and hug the client. - This is an inappropriate and potentially harmful response that may violate the client's personal boundaries and trigger more distress. The nurse should not assume that the client wants or needs physical contact, as this may remind them of their trauma or make them feel unsafe.

D) Redirect the conversation to a less distressing topic. - This is an avoidant and unhelpful response that may make the client feel ignored or invalidated. The nurse should not try to distract or divert the client from their emotions, as this can prevent them from working through their trauma.

Correct answer: A) "You should avoid driving or operating heavy machinery for at least 24 hours after your last ECT session."

Rationale: The nurse should instruct the client to avoid driving or operating heavy machinery for at least 24 hours after their last ECT session, as they may still have residual effects of anesthesia, such as drowsiness, impaired coordination, or slowed reaction time.

Incorrect options:

B) "You should expect to experience some memory loss and confusion for several months after your ECT treatment." - This is an inaccurate and alarming statement that may discourage the client from continuing their ECT treatment. The nurse should inform the client that memory loss and confusion are common side effects of ECT, but they are usually mild and transient, lasting only a few days or weeks after each session.

C) "You should discontinue your antidepressant medication once you complete your ECT course." - This is a dangerous and incorrect instruction that may increase the risk of relapse or recurrence of depression. The nurse should advise the client to continue taking their antidepressant medication as prescribed, unless otherwise instructed by their provider. Antidepressant medication can help maintain the therapeutic effects of ECT and prevent depression from returning.

D) "You should monitor your vital signs daily and report any changes to your provider." - This is an unnecessary and unrealistic instruction that may overwhelm or confuse the client. The nurse should not ask the client to monitor their vital signs daily, as this is not a routine part of ECT follow-up care. The nurse should only instruct the client to report any signs or symptoms of complications, such as severe headache, chest pain, or fever.

Correct answer: B) "You should write down your worries in a journal and set them aside until the next day."

Rationale: The nurse should suggest that the client write down their worries in a journal and set them aside until the next day, as this can help them reduce their anxiety and clear their mind before going to sleep. Writing down worries can also help the client gain perspective and identify possible solutions.

Incorrect options:

A) "You should drink a glass of wine or take a sleeping pill before going to bed." - This is an unhealthy and risky strategy that may cause more harm than good. Alcohol and sleeping pills can interfere with sleep quality, worsen anxiety symptoms, and lead to dependence or other negative effects. It is important to promote healthy sleep habits and avoid relying on substances for sleep.

C) "You should watch TV or read a book in bed until you feel sleepy." - This strategy may actually interfere with sleep as electronic devices emit blue light that can disrupt the sleep-wake cycle. It is recommended to avoid electronic screens before bedtime and create a calm and relaxing sleep environment.

D) "You should exercise vigorously right before bedtime to tire yourself out." - While exercise is beneficial for overall sleep quality, engaging in vigorous exercise right before bedtime can actually stimulate the body and make it harder to fall asleep. It is better to schedule exercise earlier in the day and allow time for the body to wind down before sleep.

Correct answer: D) Redirect the client's attention to reality-based topics and activities.

Rationale: The nurse should redirect the client's attention to reality-based topics and activities, as this can help to decrease the client's agitation, distractibility, and impulsiveness. The nurse should also use clear, concise, and calm communication with the client and set consistent limits and expectations.

Incorrect options:

A) Encourage the client to participate in group activities with other clients. - This is an incorrect intervention, as group activities may increase the client's stimulation, agitation, and inappropriate behavior. The nurse should limit the client's interactions with other clients and staff during a manic episode.

B) Provide the client with a quiet, private room and limit stimulation. - This is an incorrect intervention, as isolating the client may increase their feelings of loneliness, rejection, and paranoia. The nurse should provide the client with a safe and structured environment that allows for some social contact and supervision.

C) Allow the client to make decisions about their care and treatment. - This is an incorrect intervention, as the client may have impaired judgment, insight, and decision-making ability during a manic episode. The nurse should involve the client in their care as much as possible, but also consult with the client's family, health care provider, and legal representative if needed.

Correct answer: B) "Do you have any plans or goals for the future?"

Rationale: The nurse should ask the client about their plans or goals for the future, as this can help to assess the client's hopelessness, which is a common symptom of major depressive disorder. Hopelessness is defined as a negative outlook on oneself, one's situation, and one's future. A client who expresses no plans or goals for the future may indicate a lack of hope and motivation.

Incorrect options:

A) "Do you have any hobbies or interests that you enjoy doing?" - This is an important question to ask, as it can help to assess the client's anhedonia, which is another common symptom of major depressive disorder. Anhedonia is defined as a loss of interest or pleasure in previously enjoyed activities. However, this question does not directly assess the client's hopelessness.

C) "Do you have any friends or family members who support you?" - This is an important question to ask, as it can help to assess the client's social support network, which can influence their coping and recovery from major depressive disorder. However, this question does not directly assess the client's hopelessness.

D) "Do you have any religious or spiritual beliefs that give you comfort?" - This is an important question to ask, as it can help to assess the client's spiritual well-being, which can also influence their coping and recovery from major depressive disorder. However, this question does not directly assess the client's hopelessness.

Correct answer: C) Establish eye contact with the client and call them by name.

Rationale: The first action that the nurse should take when administering medication to a client who has schizophrenia and is experiencing auditory hallucinations is to establish eye contact with

the client and call them by name. This can help to gain the client's attention, orient them to reality, and establish rapport and trust.

Incorrect options:

A) Ask the client what they are hearing and how they are feeling. - This is an important action to take, as it can help to assess the client's hallucinations and emotional state, and provide empathy and validation. However, this is not the first action that the nurse should take, as the client may not be able to focus on the nurse's questions or respond appropriately.

B) Explain to the client what medication they are receiving and why. - This is an important action to take, as it can help to educate the client about their medication and its benefits, and obtain their informed consent. However, this is not the first action that the nurse should take, as the client may not be able to comprehend or retain the information.

D) Assess the client's vital signs and check for any adverse effects. - This is an important action to take, as it can help to monitor the client's physical condition and response to the medication. However, this is not the first action that the nurse should take, as the client may not cooperate or tolerate the assessment.

Correct answer: A) Use open-ended questions to encourage the client to express their feelings.

Rationale: Open-ended questions are those that cannot be answered with a simple yes or no, and they allow the client to explore and elaborate on their feelings, thoughts, and experiences. This helps the nurse to gain a better understanding of the client's perspective and needs, and to build trust and rapport with the client.

Incorrect options:

B) Use closed-ended questions to obtain specific information from the client. - Closed-ended questions are those that can be answered with a yes or no, or a short factual response. They are useful for obtaining specific information, such as medical history or symptoms, but they do not facilitate therapeutic communication or rapport building, as they limit the client's opportunity to express themselves fully.

C) Use leading questions to direct the client's thoughts and responses. - Leading questions are those that suggest a desired answer or imply a judgment or opinion from the nurse. They are not appropriate for therapeutic communication, as they can make the client feel pressured, manipulated, or defensive, and they can interfere with the client's autonomy and self-determination.

D) Use clichés to reassure the client and minimize their concerns. - Clichés are overused or trite expressions that have lost their original meaning or impact. They are not helpful for therapeutic communication, as they can convey a lack of empathy, sincerity, or interest from the nurse, and they can invalidate or dismiss the client's feelings and concerns.

Correct answer: C) "I'm having trouble following your thoughts. Can you slow down a bit?"

Rationale: The nurse should use a calm, clear, and concise communication style when interacting with a client who is experiencing mania, as this can help to reduce stimulation and confusion for the client. The nurse should also provide feedback on the client's behavior and speech patterns, and gently redirect the client to focus on one topic at a time.

Incorrect options:

A) "You need to calm down and stop talking so much." - This is an inappropriate response by the nurse, as it is rude, dismissive, and authoritarian. It does not acknowledge or address the underlying cause of the client's behavior, which is a symptom of their mental illness. It also does not promote therapeutic communication or rapport building, as it can make the client feel criticized, rejected, or angry.

B) "Tell me more about your plans for becoming a famous singer." - This is an inappropriate response by the nurse, as it encourages the client to elaborate on their grandiose ideas, which are unrealistic and indicative of impaired judgment. It also does not provide any feedback or guidance for the client, who may benefit from reality orientation and limit setting.

D) "You are being unrealistic and delusional. You need to face reality." - This is an inappropriate response by the nurse, as it is harsh, confrontational, and judgmental. It does not demonstrate empathy or respect for the client's feelings and experiences, which may be very real and meaningful for them. It also does not foster therapeutic communication or rapport building, as it can make the client feel attacked, humiliated, or defensive.

Correct answer: A) "I understand that this is a difficult situation for you and your family. How can I support you in making this decision?"

Rationale: The nurse should respect the client's autonomy, which is the right to make one's own decisions and choices, especially regarding end-of-life care. The nurse should also acknowledge the client's feelings and the complexity of the situation, and offer support and assistance in facilitating communication and decision making between the client and the family.

Incorrect options:

B) "I think you should reconsider your decision. Your family knows what is best for you and they love you very much." - This statement does not respect the client's autonomy, as it implies that the client's decision is wrong or invalid, and that the family's wishes should override the client's preferences. It also does not acknowledge or address the client's feelings or concerns, and it may increase the client's guilt or distress.

C) "I agree with your decision. It is your right to choose where you want to die and I will advocate for you." - This statement does not respect the client's autonomy, as it expresses the nurse's personal opinion or agreement with the client's decision, which may influence or pressure the client. It also does not acknowledge or address the family's feelings or concerns, and it may create conflict or resentment between the nurse and the family.

D) "I don't think you are in the right state of mind to make this decision. You should listen to your doctor's advice." - This statement does not respect the client's autonomy, as it questions the client's mental capacity or competence to make their own decision, and it suggests that the doctor's authority or expertise should prevail over the client's wishes. It also does not demonstrate empathy or compassion for the client, and it may undermine the client's trust or confidence in the nurse.

Correct answer: C) "What do you think is causing these symptoms?"

Rationale: The nurse should ask open-ended questions that invite the client to share their thoughts, feelings, and perceptions about their health condition and its possible causes. This can help the nurse to identify any contributing factors, such as stress, lifestyle habits, or environmental triggers, that may be associated with the client's symptoms. It can also help the nurse to assess the client's level of insight, awareness, and readiness for change.

Incorrect options:

A) "How long have you been experiencing these symptoms?" - This is a closed-ended question that can be answered with a specific time frame, such as days, weeks, or months. It does not elicit information about the possible cause of the symptoms, but rather about their duration or frequency.

B) "How do these symptoms affect your daily activities?" - This is an open-ended question that can elicit information about the impact or severity of the symptoms on the client's functioning and quality of life. It does not elicit information about the possible cause of the symptoms, but rather about their consequences or outcomes.

D) "What have you done to manage these symptoms?" - This is an open-ended question that can elicit information about the client's coping strategies, self-care practices, or treatment options for their symptoms. It does not elicit information about

the possible cause of the symptoms, but rather about their management or resolution.