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1, 4,D. 1, 4, 2,How can a nurse minimize agitation in a disturbed client?Which characteristic is most essential for the nurse to have in caring for client with mental health disorders?Which characteristic is most essential for the nurse to have in caring for clients?Which concern is most important after the initial crisis issues have been addressed?
Multiple Choice 1. A highly agitated client paces the unit and states, I could buy and sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior? A. Rates mood 8/10. Exhibiting looseness of association. Euphoric. B. Mood euthymic. Exhibiting magical thinking. Restless. C. Mood labile. Exhibiting delusions of reference. Hyperactive. D. Agitated and pacing. Exhibiting grandiosity. Mood labile. ANS: D The nurse should document that this clients behavior is Agitated and pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | **Client Need: ** Safe and Effective Care Environment 2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body toàn thân requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights ANS: B The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body toàn thân requirements R/T hyperactivity AEB weight loss. Due to the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health. KEY: Cognitive Level: Analysis | **Integrated Processes: ** Nursing Process: Analysis | Client Need: Physiological Integrity 3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains không lấy phí from injury. 4. Sleeps 6 to 8 hours a night. A. 2, 1, 3, B. 4, 1, 2,
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C. 3, 1, 4,
D. 1, 4, 2,
ANS: C
The nurse should order client outcomes based on priority in the following order: Remains không lấy phí of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients physical and safety needs. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | **Client Need: ** Safe and Effective Care Environment: Management of Care 4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body toàn thân requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment ANS: A The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be risk for suicide related to an intentional Zoloft overdose. KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | **Client Need: ** Safe and Effective Care Environment: Management of Care 5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil) ANS: B Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization. KEY: Cognitive Level: Application | Integrated Processes : Nursing Process: Assessment | **Client Need: ** Safe and Effective Care Environment 6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions the Zyprexa order. Which is the appropriate nursing reply? A. Zyprexa in combination with Eskalith cures manic symptoms. B. Zyprexa prevents extrapyramidal side effects.
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D. Symptoms indicate lithium carbonate toxicity. ANS: D The nurse should interpret that the clients symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 10. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool ANS: B The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity 11. An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order? A. This dosage is within the recommended dosage range. B. This dosage is lower than the recommended dosage range. C. This dosage is more than twice the recommended dosage range. D. This dosage is four times higher than the recommended dosage range. ANS: C The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed mg daily. KEY: Cognitive Level: Application | Integrated Processes: Implementation | **Client Need: ** Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. Treatment is compromised when clients cant sleep. B. Treatment is compromised when irritability interferes with social interactions. C. Treatment is compromised when clients have no insight into their problems. D. Treatment is compromised when clients choose not to take their medications.
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ANS: D
The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications. Symptoms of bipolar disorder will reemerge if medication is stopped. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 13. A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week? A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs. ANS: A The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity 14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge. ANS: C A client diagnosed with bipolar disorder is risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be risk for suicide. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | **Client Need: ** Safe and Effective Care Environment 15. A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, You cant do this to me. Do you know who I am? Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation ANS: A
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mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body toàn thân requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night ANS: C Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately the first signs of agitation or aggression. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | **Client Need: ** Safe and Effective Care Environment: Management of Care 20. A client who has been diagnosed with bipolar I disorder states, God has taught me how to decode the Bible. A nurse should anticipate that which combination of medications would be ordered to address this clients symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal) ANS: A The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 21. A nurse learns report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. I cant stop my sexual urges. They have led me to numerous affairs. B. Im the worlds most perceptive attorney. C. My wife is distraught about my overspending. D. The FBI is out to get me. ANS: B
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Grandiosity is defined as a belief that personal abilities are better than anyone elses. This client is experiencing delusions of grandeur, which are commonly experienced in mania. KEY: Cognitive Level: Application | Integrated Processes: Evaluation | **Client Need: ** Psychosocial Integrity 22. Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. I will limit my intake of fluids daily. B. I will maintain normal salt intake. C. I will take Lithobid on an empty stomach. D. I will increase my caloric intake to prevent weight loss. ANS: B A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurses initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems. ANS: C During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurses initial action should focus on removing the client from the stimulating environment to a calmer location. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care 24. A client diagnosed with bipolar disorder states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. What should be the priority nursing action? A. Assess the clients vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away. ANS: A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-
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ANS: B
Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | **Client Need: ** Health Promotion and Maintenance 28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client? A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers ANS: A Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity Multiple Response 29. Which of the following instructions regarding lithium therapy should be included in a nurses discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume least 2,500 to 3,000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1,500 mL per day. ANS: A, B, C The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies 30. Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age.
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D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant. ANS: A, B It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder. KEY: Cognitive Level: Application | **Integrated Processes: ** Teaching/Learning | **Client Need: ** Psychosocial Integrity
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How can a nurse minimize agitation in a disturbed client?
How can an agitation in a disturbed client be minimized?. Increasing stimulation.. Limiting unnecessary interaction.. Increasing appropriate sensory percenption.. Ensuring constant client and staff contact..Which characteristic is most essential for the nurse to have in caring for client with mental health disorders?
Empathy. A Registered Psychiatric Nurse can never forget that they are treating a person's mind, personality and emotions. While empathy is helpful when it comes to physical treatment, it is indispensable for Psychiatric Nursing.Which characteristic is most essential for the nurse to have in caring for clients?
Compassionate One of the most important qualities of a good nurse is compassion. In their career, nurses will see patients suffer. Beyond simply offering a solution, they must be able to express compassion for patients and their families.Which concern is most important after the initial crisis issues have been addressed?
The primary concern in a crisis has to be public safety. A failure to address public safety intensifies the damage from a crisis. Reputation and financial concerns are considered after public safety has been remedied. Tải thêm tài liệu liên quan đến nội dung bài viết Which therapeutic nursing intervention would redirect a hyperactive manic client