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NurseDive Free Nursing Practice Question
A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
A. Ignore the client's behavior, realizing it is consistent with her illness.
Ignoring the client's disruptive behavior is not a suitable approach, as it could lead to a chaotic environment on the unit and potentially escalate the situation.
B. Set limits on the client's behavior and be consistent in approach.
Setting limits on the client's behavior is essential to maintain a therapeutic environment for all clients on the unit. Consistency in approach helps establish clear boundaries and expectations.
C. Ask the client to recommend consequences for her disruptive behavior.
Asking the client to recommend consequences for her disruptive behavior might not be appropriate, as it shifts the responsibility from the nursing staff to the client. Additionally, during a manic episode, the client's judgment might be impaired.
D. Warn the client that further disruptions will result in seclusion.
Warning the client about seclusion is an extreme measure that should be reserved for situations where the client's safety or the safety of others is at risk. It's important to start with less restrictive interventions, such as setting limits.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Similar Questions
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?
A. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.".
In the denial phase of the grief process, individuals often use denial as a defense mechanism to cope with the overwhelming reality of their situation. This response reflects the client's disbelief in the doctor's prognosis, attributing it to an ulterior motive. The client's statement of exaggeration indicates their attempt to rationalize the situation, which is a characteristic of the denial phase.
B. "The doctor has been so good to me. I know he has tried everything he can. It is just my time.".
This response does not indicate denial but rather an acceptance of the situation and a recognition of the doctor's efforts. The client acknowledges that everything possible has been done and that it's their time to face the inevitable, which is not aligned with the denial phase.
C. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.".
While lack of energy and motivation can be associated with the grief process, this response doesn't directly reflect denial. The focus here is on physical and emotional exhaustion rather than denial of the terminal diagnosis.
D. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer."
This response expresses frustration with the doctor's competence, but it doesn't reflect denial. The client's disbelief in the doctor's medical knowledge is a different coping mechanism rather than denial of their own situation.
An accomplished student has won an award and will need to accept the award as well as give a short speech to thank faculty. The student is fearful of public speaking. The student consults a nurse at the Student Health Center. The nurse is aware that social phobias are often treated using:.
A. Response prevention.
Response prevention is a therapeutic technique used in exposure and response prevention therapy for anxiety disorders, especially OCD. It involves intentionally refraining from performing compulsive behaviors in order to reduce anxiety. However, it's not the primary treatment for social phobias.
B. Modeling.
Modeling involves observing and imitating someone else's behavior to learn and acquire new skills. While it can be used in various therapeutic approaches, it's not the primary treatment for social phobias.
C. Meditation.
Meditation can be helpful for managing anxiety and stress, but it's not the primary treatment for social phobias. Meditation techniques are generally broader in application and may not specifically address the symptoms of social phobia.
D. Beta blockers.
Beta blockers are often used to manage the physical symptoms of anxiety, such as rapid heart rate, tremors, and sweating. They can be particularly helpful for situations where anxiety-related symptoms, like those associated with public speaking, need to be controlled quickly. Thus, beta blockers are commonly used to address social phobias and the anxiety associated with them.
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
A. Confront the client about the senseless nature of the repetitive behaviors.
Confronting the client about the senseless nature of their compulsive behaviors can lead to resistance, defensiveness, and increased anxiety. It's important to approach clients with OCD in a supportive and non-judgmental manner.
B. Isolate the client for a period of time.
Isolating the client is not an appropriate intervention. It can exacerbate anxiety and distress, potentially worsening the symptoms of OCD. Social isolation is generally not recommended in mental health care.
C. Plan the client's schedule to allow time for rituals.
Planning the client's schedule to allow time for rituals is a therapeutic approach called "ritual accommodation." It involves gradually adjusting the schedule to accommodate rituals while also working on reducing the frequency and intensity of those rituals over time.
D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Setting strict limits on compulsive behaviors is not the best approach. While structure and rules are important in a mental health facility, individuals with OCD need a more gradual and understanding approach to manage their compulsions.