The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, the nurse determines that the most appropriate action would be to:
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Solution
With assistance, escort the manic client to her room and administer Haldol as prescribed if needed
The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to Haldol.
Option B may increase the agitation that already exists in this client.
Option C: Orientation will not halt the behavior.
Option D: Telling the client that the behavior is not appropriate already has been attempted by the nurse.
A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client’s mother begins to cry and states “My son’s brain will be destroyed. How can the doctor do this to him?” The nurses best response is:
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Solution
“It sounds as though you have some concerns about the ECT procedure. Why don’t we sit down together and discuss any concerns you may have.”
The nurse encourages the client and the family to verbalize fears and concerns.
Options A, B, and C: The other options avoid dealing with concerns and are blocks to communication.
The nurse reviews the activity schedule for the day and plans which activity for the manic client?
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Solution
Tetherball
A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow the use of excess energy yet not endanger others during the process.
Options A, C, and D are relatively sedated activities that require concentration, a quality that is lacking in the manic state. Such activities lead to increased frustration and anxiety for the client. Tetherball is an exercise that uses the large muscle groups of the body and is a great way to expand the increased energy that the client is experiencing.
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse’s immediate intervention is the client’s:
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Solution
Nonstop physical activity and poor nutritional intake
Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client’s possible symptomatology. Option C, however, clearly presents a problem that compromises one’s physiological integrity and needs to be addressed immediately.
A depressed client is ready for discharge. The nurse feels comfortable that the client has a good understanding of the disease process when the client states:
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Solution
“It’s important for me to eat well, exercise, and to take my medication. If I begin to lose my appetite or not sleep well, I’ve got to get in to see my doctor.”
The exact cause of depression is not known but is believed to be related to biochemical disruption of neurotransmitters in the brain. Diet, exercise, and medication are recognized treatment for the disease process.
A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client’s:
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Solution
Disturbed thought processes
Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option A is correct.
The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure… I can’t do anything right!” The best nursing response would be:
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Solution
To identify recent behaviors or accomplishments that demonstrate skill ability.
Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self-talk and distorted the cognitive view of self. Silence may be interpreted as agreement.
Options A and C give advice and devalue the client’s feelings.
In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best?
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Solution
Provide a structured daily program of activities and encourage the client to participate.
A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Option C is a forceful and absolute approach.
Option C is a forceful and absolute approach.
A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is:
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Solution
Consult with the nutritionist, offer the client several small meals per day and schedule brief nursing interactions with the client during these times.
Change in appetite is one of the major symptoms of depression.
Option C: Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake.
The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client?
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Solution
Writing
Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension.
Options A, C, and D: Competitive games can stimulate aggression and increase psychomotor activity.