Which of the following short term goals is most appropriate for a client with bipolar disorder who is having difficulty sleeping?
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Solution
Develop a sleep ritual
A sleep ritual or nighttime routine helps the client to relax and prepare for sleep.
Option A: Obtaining sleep medication is a temporary solution.
Option B: Working on problem solving may excite the client rather than tire him.
Option C: Exercise before retiring is inappropriate.
In conferring with the treatment team, the nurse should make which of the following recommendations for a client who tells the nurse that everyday thoughts of suicide are present?
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Solution
Intensive inpatient treatment
For a client thinking about suicide on a daily basis, inpatient care would be the best intervention. Although a no-suicide contract is an important strategy, this client needs additional care. The client needs a more intensive level of care than weekly outpatient therapy. Immediate intervention is paramount, not a second psychiatric opinion.
What information is important to include in the nutritional counseling of a family with a member who has bipolar disorder?
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Solution
If the intake of sodium increases, the lithium level will decrease.
Any time the level of sodium increases, such as with a change in the dietary intake, the levels of lithium will decrease.
Which of the following communication guidelines should the nurse use when talking with a client experiencing mania?
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Solution
Focus and redirect the conversation as necessary
To decrease stimulation, the nurse should attempt to redirect and focus the client’s communication, not allow the client to talk about different topics.
Option A: By addressing the client in a light and joking manner, the conversation may contribute to the client’s feeling out of control.
Option D: For a manic client, it’s best to ask closed questions because open-ended questions may enable the client to talk endlessly, again possibly contributing to the client’s feeling out of control.
Which of the following psychological symptoms would the nurse expect to find in a hospitalized client who is the only survivor of a train accident?
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Solution
Denial
Denial can act as a protective response.
Option B: The client tends to be overwhelmed and disorganized by the trauma, not indifferent to it.
Option C: Perfectionism is more commonly seen in clients with eating disorders, not in clients with PTSD.
Option D: Clients who have had a severe trauma often experience an inability to trust others.
Which of the following nursing actions would be included in a care plan for a client with PTSD who states the experience was “bad luck”?
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Solution
Assist the client in defining the experience
The client must define the experience as traumatic to realize the situation wasn’t under his personal control.
Option A: Encouraging the client to verbalize the experience without first addressing the denial isn’t a useful strategy.
Option C: The client can move on with life only after acknowledging the trauma and processing the experience.
Option D: Acknowledgement of the actual trauma and verbalization of the event should come before the acceptance of feelings.
Select the appropriate interventions for caring for the client in alcohol withdrawal.
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Solution
Answers:A, D, and E.
When the client is experiencing withdrawal of alcohol, the priority of care is to prevent the client from harming himself or others. The nurse would monitor vital signs closely and report abnormal findings. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically.
Option B: The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible.
Option C: Adequate nutritional and fluid intake needs to be maintained.
A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go. I don’t want anymore treatment. I have things that I have to do right away.” The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client’s concerns with the client, the client dresses and begins to walk out of the hospital room. The most important nursing action is to:
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Solution
Call the nursing supervisor.
A nurse can be charged with false imprisonment if a client is made to believe wrongfully that the client cannot leave the hospital. Most health care facilities have documents that the client is asked to sign that relate to the client’s responsibilities when the client leaves against medical advice. The client should be asked to sign this document before leaving.
Options A and B: Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.
Option C: The nurse should request that the client wait to speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold him against his will.
The client has been hospitalized and is participating in a substance abuse therapy group sessions. On discharge, the client has consented to participate in AA community groups. The nurse is monitoring the client’s response to the substance abuse sessions. Which statement by the client best indicates that the client has developed effective coping response styles and has processed information effectively for self use?
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Solution
“I’m looking forward to leaving here. I know that I will miss all of you. So, I’m happy and I’m sad, I’m excited and I’m scared. I know that I have to work hard to be strong and that everyone isn’t going to be as helpful as you people.”
In option C the client is expressing real concern and ambivalence about discharge from the hospital. The client also demonstrates reality in that statement.
Option A: In the defense mechanism of denial the person denies reality.
Option B: The client is relying heavily on others, and the client’s focus of control is external.
Option 4: The client is concrete and procedure oriented; again the client identifies that “Nothing will go wrong that way” if the client follows all the directions.
The nurse determines that the wife of an alcoholic client is benefiting from attending Al-Anon group when she hears the wife say:
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Solution
“I no longer feel that I deserve the beatings my husband inflicts on me.”
Al-Anon support groups are protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavior changes. Option 2 is the most healthy response because is exemplifies and understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse “I should get out of this bad situation.” The most helpful response by the nurse would be:
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Solution
“What do you find difficult about this situation?”
The most helpful response is one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can foster dependency.
Options A and B: The nurse should not agree with the client, nor should the nurse request that the client provide explanations.
The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal. Which of the following would alert the nurse to the potential for delirium tremors?
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Solution
Hypertension, changes in LOC, hallucinations
Some of the symptoms associated with delirium tremors typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, and changes in LOC, agitation, fever, and delusions.
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. The most appropriate maintenance goal should focus on which of the following?
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Solution
Identifying anxiety-producing situations
Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus.
Option A: Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths.
Option C: Ignoring feelings will not resolve anxiety.
Option D: Elimination anxiety from life is impossible.
A woman comes into the ER in a severe state of anxiety following a car accident. The most appropriate nursing intervention is to:
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Solution
Remain with the client
If a client with severe anxiety is left alone; the client may feel abandoned and become overwhelmed.
Option B: Placing the client in a quiet room is also important, but the nurse must stay with the client.
Option C: Teaching the client deep breathing or relaxation is not possible until the anxiety decreases.
Option D: Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.
Select all nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior.
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Solution
Answers: A, D, and E.
Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a non-punishment manner; and assisting the client in identifying strengths and in testing out alternative behaviors for obtaining needs.
Option B: Enforcing rules and informing the client that he or she will not be allowed to attend group therapy sessions is a violation of the client’s rights.
Option C: Ensuring the client knows that he or she is not in charge of the nursing unit is inappropriate, power struggles need to be avoided.