Choice A rationale:

While disorganized speech can be a symptom of acute mania, it is not a specific indicator. It can also be present in other mental health conditions, such as schizophrenia.

In this scenario, the client's speech is not described as disorganized. Instead, the client's experience is centered around auditory hallucinations.

Auditory hallucinations, specifically hearing voices, are a hallmark feature of acute mania.

These voices can be commanding, instructive, or critical, and they often align with the individual's elevated mood and grandiose thinking.

In this case, the voices are telling the client to write a novel, which is consistent with the expansive and creative thinking that often characterizes acute mania.

Choice B rationale:

Dressing in all black is not a specific indicator of acute mania.

It could be a matter of personal preference, cultural expression, or a symptom of a different mental health condition, such as depression.

While changes in clothing style or appearance can occur during manic episodes, they are not a defining characteristic for diagnosing acute mania.

Choice C rationale:

Weight gain is not a specific symptom of acute mania.

While changes in appetite and weight can occur during manic episodes, they are not reliable indicators to diagnose acute mania.

Some individuals with acute mania may experience weight loss due to increased activity levels and decreased sleep, while others may gain weight due to increased impulsivity and poor dietary choices.

Choice D rationale:

The client's report of hearing voices telling him to write a novel is the most significant finding that supports the diagnosis of acute mania.

Auditory hallucinations are a common feature of acute mania, and they often involve hearing voices that instruct or command the individual to perform certain actions.

The client's belief that voices are compelling them to write a novel aligns with this characteristic symptom of acute mania.

Choice A rationale:

Progressive muscle relaxation (PMR) is a well-established technique for stress reduction. It involves systematically tensing and releasing different muscle groups throughout the body. This process helps to release physical tension, promote relaxation, and decrease feelings of stress and anxiety.

PMR has been shown to be effective in reducing stress and anxiety in various populations, including individuals with chronic pain, anxiety disorders, and sleep difficulties.

It is a simple, safe, and accessible technique that can be practiced independently without any special equipment or training.

Choice B rationale:

While sleeping in can provide temporary relief from stress, it is not considered an adaptive coping strategy in the long term.

Oversleeping can disrupt sleep patterns and circadian rhythms, which can actually worsen stress and anxiety in the long run.

It can also lead to social isolation and decreased productivity, further compounding stress.

Choice C rationale:

While distraction techniques, such as thinking about a favorite vacation, can provide temporary relief from stress, they do not address the underlying causes of stress.

Overreliance on distraction can prevent individuals from developing more effective coping strategies for managing stress in the long term. Choice D rationale:

Social isolation is generally considered a maladaptive coping strategy. While it may provide temporary relief from overwhelming situations, it can lead to increased feelings of loneliness, disconnection, and rumination.

It can also prevent individuals from seeking support and developing more effective coping strategies.

Choice E rationale:

Social support is a crucial factor in stress management. Connecting with supportive friends and loved ones can provide emotional comfort, reduce feelings of isolation, and promote a sense of belonging.

Positive social interactions can also buffer the negative effects of stress and promote resilience.

Choice A rationale:

I will contact my provider if I have difficulty urinating.

Chlorpromazine has anticholinergic effects, which can cause urinary retention. This means the medication can interfere with the normal function of the bladder, making it difficult to empty completely. Difficulty urinating can lead to bladder distention, urinary tract infections, and even kidney damage if left untreated.

It's crucial for the client to recognize this potential side effect and seek medical attention promptly if it occurs. Early intervention can help prevent complications and ensure proper bladder management.

By understanding this potential side effect and the importance of seeking help, the client demonstrates a grasp of the teaching provided.

Choice B rationale:

I might notice an increased frequency of my menstrual cycle.

Chlorpromazine does not typically affect menstrual frequency. While some antipsychotic medications can cause menstrual irregularities, chlorpromazine is not commonly associated with this effect.

If a client experiences changes in their menstrual cycle while taking chlorpromazine, it's important to discuss it with their healthcare provider to rule out other potential causes.

Choice C rationale:

These medications might cause breast tissue to atrophy.

Chlorpromazine is not known to cause breast atrophy. Breast atrophy, or shrinkage of breast tissue, can occur due to hormonal changes, aging, or certain medical conditions.

However, it's not a common side effect of chlorpromazine.

Choice D rationale:

I am at a decreased risk for infection while taking these medications.

Chlorpromazine does not decrease the risk of infection. In fact, it may slightly increase the risk of infection due to its potential to suppress the immune system.

It's essential for clients taking chlorpromazine to practice good hygiene and infection prevention measures to protect themselves from illness.

A rationale:

Incorrect. While patients typically do sleep for a period after ECT, the duration is usually shorter, around 30-60 minutes.

Providing inaccurate information about the length of sleep can lead to confusion and anxiety for the patient.

Evidence: Studies have shown that the average recovery time following ECT is around 30-60 minutes, with most patients feeling alert and oriented within that time frame. (Source: NIH.gov) Choice B rationale:

Incorrect. While ECT can be highly effective in treating depression, it is not considered a cure. It's important to manage expectations and emphasize that ECT is a treatment option that can significantly improve symptoms but may not guarantee a complete cure.

Evidence: Research indicates that ECT has a remission rate of approximately 50-70% in patients with severe depression, meaning that many patients experience a significant reduction or disappearance of symptoms. However, relapse rates can range from 30-50%, indicating that ongoing maintenance treatment is often necessary. (Source: American Psychiatric Association)

Choice C rationale:

Incorrect. Muscle relaxants, not seizure-preventing medications, are administered during ECT to protect the patient from injury during the induced seizure. It's crucial to clarify this distinction to avoid misunderstandings about the procedure's mechanism of action.

Evidence: Standard ECT protocols involve the use of a short-acting muscle relaxant, such as succinylcholine, to prevent muscle contractions during the seizure. This helps to minimize the risk of physical injury and ensure patient safety. (Source: Healthline.com)

Choice D rationale:

Correct. Temporary memory loss is a common side effect of ECT, and it's essential to inform patients about this potential issue to prepare them for the experience and address any concerns they may have.

Evidence: Studies have shown that approximately 40-50% of patients experience some degree of memory impairment following ECT, primarily affecting short-term memory of events occurring around the time of treatment. However, this memory loss is usually temporary and resolves within a few weeks or months for most patients. (Source: Studocu.com)

Choice A rationale:

Pseudoparkinsonism is an extrapyramidal side effect (EPSE) of antipsychotic medications, particularly first-generation antipsychotics (FGAs) like haloperidol, that closely resembles the symptoms of Parkinson's disease. It's characterized by:

Stooped posture: A forward-leaning posture, often with rounded shoulders and a head that is bent forward.

Shuffling gait: Small, slow steps with reduced arm swing, often described as a "shuffling" or "dragging" walk.

Rigidity: Increased muscle stiffness throughout the body, leading to resistance to movement and a feeling of tightness.

Bradykinesia: Slowness of movement, both in initiating and completing actions.

Tremor: Involuntary shaking, often most noticeable in the hands, but can also affect the arms, legs, head, or jaw.

Masked facies: A decreased facial expression, often described as a "flat" or "expressionless" face.

Mechanism of pseudoparkinsonism:

Haloperidol primarily blocks dopamine D2 receptors in the nigrostriatal pathway of the brain.

Dopamine plays a crucial role in motor control, and its blockade in this pathway leads to a disruption in the balance of dopamine and acetylcholine, another neurotransmitter involved in movement.

This imbalance results in the characteristic symptoms of pseudoparkinsonism.

Risk factors for pseudoparkinsonism:

Older age

Female sex

Higher doses of antipsychotic medication

Prolonged use of antipsychotic medication

History of Parkinson's disease or other movement disorders

Presence of other EPSEs

Management of pseudoparkinsonism:

Dose reduction: If possible, the dose of the antipsychotic medication may be reduced.

Switching to a different antipsychotic: Some antipsychotics, such as second-generation antipsychotics (SGAs), have a lower risk of causing EPSEs.

Anticholinergic medications: These medications can help to counteract the effects of dopamine blockade on the acetylcholine system, but they can have their own side effects, such as dry mouth, constipation, and urinary retention.

Amantadine: This medication can also be used to treat pseudoparkinsonism, but it has the potential to cause side effects such as insomnia, anxiety, and livedo reticularis (a mottled skin rash).

Choice D rationale:

Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.

Blurred vision and nausea are common early symptoms of lithium toxicity.

Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.

The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.

The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.

Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.

Choice A rationale:

Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.

It is important for the nurse to take more decisive action to prevent further toxicity.

Choice B rationale:

Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.

It is important for the nurse to take immediate action to protect the client's health.

Choice C rationale:

Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.

This is not a safe or appropriate action for the nurse to take in this situation.

Choice A rationale:

Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.

It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.

It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.

Choice B rationale:

Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.

This information can be used to develop a safety plan and to help the client manage their symptoms.

It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.

Choice C rationale:

Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.

It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.

It can also damage the therapeutic relationship between the nurse and the client.

Choice D rationale:

Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.

While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.

Choice A rationale:

While encouraging decision-making can be empowering for some individuals with depression, it may not be appropriate for those with severe depressive disorder.

Individuals with severe depression often experience significant anhedonia (loss of interest in activities), fatigue, and difficulty concentrating, which can make decision-making overwhelming and even worsen their symptoms.

It's important to assess the client's individual level of functioning and decision-making capacity before implementing this intervention.

Choice C rationale:

Providing a selection of activities can be helpful, but it's crucial to tailor the activities to the client's interests and energy level.

Offering too many choices or activities that are too demanding can be counterproductive.

It's essential to collaborate with the client to identify activities that are meaningful and achievable, and to gradually increase the level of activity as tolerated.

Choice D rationale:

Playing a game of chess can be a stimulating and enjoyable activity, but it may not be appropriate for all clients with severe depression.

Chess requires cognitive focus and strategic thinking, which can be challenging for individuals experiencing cognitive impairment or fatigue associated with depression.

It's important to assess the client's cognitive abilities and interests before suggesting this activity.

Rationale for the correct answer, B:

Spending time with the client offers several benefits:

Conveys caring and support: It demonstrates to the client that they are not alone and that someone cares about their wellbeing.

Provides opportunities for therapeutic communication: Spending time together allows for meaningful conversations, which can help the client express their feelings, concerns, and experiences.

Facilitates observation and assessment: The nurse can observe the client's mood, behavior, and interactions, which can inform treatment planning and evaluation.

Promotes engagement and participation: Spending time with the client can encourage them to engage in other therapeutic activities and interventions.

Builds rapport and trust: Developing a strong therapeutic relationship is essential for effective treatment of depression.

Choice A rationale:

Establishing rapport with the client is essential when caring for someone experiencing acute anxiety. It creates a foundation of trust and understanding, which can help the client feel more comfortable and willing to engage in therapeutic interventions. Here's a detailed explanation of why rapport is crucial in this context:

Reduces Anxiety: A strong rapport can help to reduce the client's anxiety by fostering a sense of safety and security. When a client feels understood and supported, it can help to calm their nervous system and decrease the intensity of their anxiety symptoms.

Increases Communication: Effective communication is essential for identifying the cause of anxiety and developing appropriate interventions. When a nurse has a good rapport with a client, the client is more likely to be open and honest about their thoughts, feelings, and experiences. This can lead to a more accurate assessment and a more effective treatment plan.

Improves Cooperation: Clients who have a good rapport with their nurse are more likely to cooperate with treatment recommendations. This is because they trust the nurse's expertise and feel confident that the nurse has their best interests in mind.

Enhances Coping: A strong therapeutic relationship can help to improve the client's coping skills. The nurse can provide support, encouragement, and guidance as the client learns to manage their anxiety.

Techniques for establishing rapport:

Active listening: Pay close attention to the client's verbal and nonverbal communication, demonstrating that you are genuinely interested in what they have to say.

Empathy: Show understanding and compassion for the client's experiences and feelings.

Respect: Treat the client with dignity and respect, acknowledging their autonomy and choices.

Genuineness: Be authentic and honest in your interactions with the client.

Trustworthiness: Demonstrate that you are reliable and dependable, and that you will maintain confidentiality.

Cultural sensitivity: Be aware of and respect the client's cultural background and beliefs.

Choice B rationale:

Avoiding eye contact can convey disinterest, disrespect, or dishonesty, which can further heighten anxiety. Maintaining appropriate eye contact demonstrates attentiveness, empathy, and understanding, which can help to build trust and rapport.

Choice C rationale:

Speaking in a high-pitched voice can be perceived as agitated or tense, which can exacerbate the client's anxiety. It's essential to speak in a calm, soothing, and reassuring tone to promote relaxation and a sense of safety.

Choice D rationale:

Validating the client's feelings and identifying the cause of anxiety are crucial steps in effective anxiety management.

Validation helps the client feel understood and accepted, while identifying the cause can guide the development of appropriate interventions to address the underlying triggers.

Choice A rationale:

Administering a PRN antianxiety medication may be appropriate in some cases, but it should not be the first action taken. Medications can take time to work, and they may not be effective in all cases. Additionally, there is a risk of side effects, such as drowsiness or impaired coordination.

It is important to first try non-pharmacological interventions, such as staying with the client in a quiet place and providing reassurance.

If these interventions are not effective, then medication may be considered.

Choice B rationale:

Staying with the client in a quiet place is the most appropriate first action to take when a client is experiencing a panic attack.

This provides reassurance and support, and it can help to reduce the client's anxiety.

The nurse can also encourage the client to use relaxation techniques, such as deep breathing or progressive muscle relaxation. However, it is important to note that the client may not be able to focus on these techniques until they have calmed down somewhat.

Choice C rationale:

Teaching the client how to perform relaxation techniques can be helpful, but it is not the most appropriate first action to take during a panic attack. The client is likely to be too agitated to focus on learning new techniques at this time.

Choice D rationale:

Asking the client what she was contemplating just before the attack commenced is not appropriate at this time. It is important to focus on helping the client to calm down and feel safe, rather than on exploring the underlying causes of the panic attack.

This can be done later, when the client is feeling more stable.

Rationale for Choice A:

Diuretics are not routinely prescribed with lithium. While diuretics can increase the excretion of lithium, this can also lead to decreased lithium levels and potentially reduced effectiveness. Therefore, diuretics are generally only used in specific situations, such as when a client has lithium-induced edema or congestive heart failure. In such cases, the client's lithium levels would be closely monitored to ensure they remain within the therapeutic range.

Rationale for Choice B:

Weight gain is not a common manifestation of lithium toxicity. In fact, weight gain is a potential side effect of lithium therapy, but it is not typically associated with lithium levels reaching a toxic range. Other signs and symptoms of lithium toxicity include:

Tremor

Nausea and vomiting

Diarrhea

Confusion

Slurred speech

Ataxia

Seizures

Coma

Rationale for Choice C:

Monitoring lithium levels is essential to ensure that the client is receiving a therapeutic dose and to avoid toxicity. Lithium has a narrow therapeutic index, meaning that there is a small difference between the dose that is effective and the dose that is toxic. Regularly checking lithium levels allows the healthcare provider to adjust the dose as needed to maintain a safe and effective level.

The initial lithium level is typically checked within 3 to 5 days of starting the medication, and then periodically thereafter.

The frequency of monitoring may vary depending on the client's individual factors, such as age, kidney function, and other medications they are taking.

Rationale for Choice D:

Lithium is not typically discontinued after a specific period of time. It is often used as a long-term treatment for bipolar disorder to prevent the recurrence of manic and depressive episodes. The decision to discontinue lithium is made on a caseby-case basis, in consultation with the client and their healthcare provider.

Choice A rationale:

Concrete thinking is a cognitive distortion characterized by a rigid and literal interpretation of events and experiences. Individuals with concrete thinking often struggle to grasp abstract concepts, metaphors, or multiple perspectives. They tend to view situations in black-and-white terms, with little room for nuance or ambiguity.

Statement A, "I am aware that each problem has only one solution," exemplifies concrete thinking in several ways:

Absolute language: The use of the phrase "each problem has only one solution" suggests a fixed and inflexible mindset. It implies that there is only one correct way to approach any given problem, disregarding the possibility of alternative solutions or perspectives.

Oversimplification: The statement reduces the complexity of problem-solving to a single, definitive answer. It fails to acknowledge the multifaceted nature of most problems, which often require creative thinking, flexibility, and consideration of multiple factors.

Lack of abstract reasoning: The inability to consider multiple solutions or perspectives is a hallmark of concrete thinking. It reflects a difficulty in grasping abstract concepts and hypothetical scenarios, leading to a more rigid and literal interpretation of reality.

Intolerance of ambiguity: Concrete thinkers often experience discomfort with uncertainty or open-ended situations. They prefer clear-cut answers and definitive conclusions, which can lead to frustration and anxiety when faced with complex or ambiguous problems.

A rationale:

Going to another room and reading for 20 minutes when waking up at night is a recommended strategy for managing insomnia. This technique helps to break the cycle of lying in bed awake and worrying, which can worsen insomnia. Reading can be a relaxing activity that can help to promote sleepiness. It's important to choose a book that is not too stimulating and to avoid reading in bright light.

Choice B rationale:

Stopping napping in the afternoon is also a recommended strategy for managing insomnia. Napping can interfere with nighttime sleep by reducing sleep drive. It's best to avoid napping altogether or to limit naps to 30 minutes or less early in the afternoon.

Choice C rationale:

Watching television in the bedroom is not recommended for managing insomnia. The light from the television can suppress the production of melatonin, a hormone that helps to regulate sleep. The noise from the television can also be stimulating and make it difficult to fall asleep. It's best to avoid watching television in the bedroom or to turn off the television at least 30 minutes before bedtime.

Choice D rationale:

Eating the evening meal at least 3 hours before bed is generally a good practice for sleep hygiene. Eating too close to bedtime can lead to indigestion, which can make it difficult to fall asleep. It's best to avoid heavy, fatty, or spicy foods before bed.

The rationale for Choice A:

Limiting time for rituals to 30 minutes each day may not be effective and could potentially increase anxiety. Individuals with OCD often feel a strong compulsion to perform their rituals, and abruptly restricting their ability to do so can heighten distress and lead to increased attempts to engage in the rituals, even in a covert manner. This can create a cycle of anxiety and frustration.

Gradual exposure and response prevention (ERP) therapy is a more effective approach to reducing ritualistic behaviors. It involves gradually exposing the individual to anxiety-provoking stimuli while helping them to resist engaging in their compulsions. This process is done in a controlled and supportive environment, to help the individual learn to manage their anxiety and reduce their reliance on rituals.

Rationale for Choice B:

Providing a stimulating environment is not generally recommended for individuals with OCD. Excessive stimulation can exacerbate anxiety and trigger compulsive behaviors. A calmer and more structured environment is often more beneficial.

Individuals with OCD often thrive in environments that provide predictability and a sense of control. A structured schedule can help to reduce uncertainty and create a sense of order, which can in turn help to reduce anxiety and the urge to engage in compulsive behaviors. Rationale for Choice C:

Negative reinforcement is not an appropriate or effective intervention for OCD. It involves punishing or removing a desired stimulus in response to a behavior, with the aim of decreasing the likelihood of that behavior occurring again. However, this approach can be counterproductive in OCD, as it can increase anxiety and make the individual more likely to engage in their rituals in order to avoid the negative consequences.

Positive reinforcement, such as praise and encouragement, is more effective in promoting desired behaviors. This approach focuses on rewarding the individual for making progress in reducing their ritualistic behaviors, which can help to increase motivation and create a more positive and supportive environment for change.

Rationale for Choice D:

Providing a structured schedule of activities can be a very effective intervention for OCD. It can help to reduce anxiety, provide a sense of control, and minimize the time available for engaging in compulsive rituals.

A structured schedule can include a variety of activities, such as:

Mealtimes

Personal hygiene routines

Work or school activities

Leisure activities

Relaxation exercises

Social interactions

The schedule should be tailored to the individual's specific needs and preferences. It is important to ensure that the activities are enjoyable and meaningful to the individual, as this will increase their motivation to participate.

The nurse can work with the individual to develop a schedule that is realistic and achievable. The schedule should be reviewed and adjusted regularly as the individual makes progress.

Choice A rationale:

Losing 10 lb after the death of a loved one is not uncommon, especially within the first few months of grieving. It can be due to decreased appetite, changes in eating habits, or increased physical activity. While it's important to monitor weight loss and ensure adequate nutrition, it doesn't necessarily indicate maladaptive grieving on its own.

Grief can often lead to changes in appetite and weight. Some people may experience a loss of appetite and unintentional weight loss, while others may find themselves overeating or gaining weight. These changes are often temporary and subside as the grieving process progresses.

It's important to consider the client's overall health and well-being when assessing weight loss. If the client is experiencing significant weight loss, it's important to rule out any underlying medical conditions that may be contributing to it.

Choice B rationale:

Visiting a loved one's grave is a common way to grieve and remember them. It can be a way to feel connected to the deceased, express love and sorrow, and find solace. It's a normal part of the grieving process and doesn't necessarily indicate maladaptive grieving.

Grieving individuals often find comfort in visiting the gravesite of their loved one. It can be a place to reflect, remember, and feel close to the deceased. Visiting a gravesite can also be a way to honor the loved one's memory and express continued love and respect.

The frequency of grave visits can vary from person to person. Some individuals may visit frequently, while others may only visit on special occasions or anniversaries. There is no right or wrong way to grieve, and what matters most is that the individual finds a way to express their grief in a way that feels right for them.

Choice D rationale:

Difficulty sleeping is a common symptom of grief. It can be caused by a variety of factors, including anxiety, sadness, and changes in sleep patterns. While it can be distressing, it's not always a sign of maladaptive grieving.

Grief can disrupt sleep patterns in a number of ways. It can make it difficult to fall asleep, stay asleep, or both. It can also lead to nightmares, night sweats, and early morning awakenings. These sleep disturbances can be both physically and emotionally draining.

There are a number of things that can be done to improve sleep during grief. These include establishing a regular sleep schedule, creating a relaxing bedtime routine, avoiding caffeine and alcohol, and getting regular exercise. If sleep problems persist, it's important to seek professional help.

Protecting the client and others from impulsive behavior is the nurse's priority intervention for a client experiencing an acute manic episode. This is because impulsive behavior is a hallmark of mania and can lead to potentially harmful or dangerous consequences for the client and those around them.

Here is a detailed rationale for this choice, addressing key aspects of impulsive behavior in mania and the nurse's role in managing it:

Impulsive Behavior in Mania:

Impaired judgment: During a manic episode, the client's ability to make rational decisions is significantly impaired. They may engage in activities without considering the potential risks or consequences.

Increased energy and activity levels: Mania is characterized by excessive energy and activity, often manifested as restlessness, agitation, and a decreased need for sleep. This heightened energy can fuel impulsive actions.

Grandiosity and risk-taking: Clients in a manic state often experience inflated self-esteem and a sense of invincibility, which can lead to risky behaviors such as reckless driving, spending sprees, or sexual promiscuity.

Distractibility and lack of focus: The client's attention span is often shortened during mania, making it difficult for them to concentrate or follow through on tasks. This can contribute to impulsive decision-making.

Impaired impulse control: Mania directly affects the brain's ability to regulate impulses. This neurological impairment makes it challenging for the client to resist urges or temptations.

Nursing Interventions to Protect Against Impulsive Behavior:

Close monitoring: The nurse should closely observe the client's behavior and intervene promptly to prevent harmful actions. This may involve setting limits, redirecting the client's energy, or initiating one-on-one supervision.

Structured environment: Providing a structured and predictable environment can help reduce the client's anxiety and impulsivity. This includes establishing clear expectations, maintaining a consistent routine, and minimizing overstimulation.

Medication management: Medications such as mood stabilizers and antipsychotics can help regulate mood and reduce impulsive behaviors. The nurse plays a crucial role in administering these medications as prescribed and monitoring their effectiveness.

Therapeutic communication: The nurse can use therapeutic communication techniques to help the client identify triggers for impulsive behavior, develop coping strategies, and make safer choices.

Collaboration with the healthcare team: The nurse should collaborate with other members of the healthcare team, including psychiatrists, therapists, and social workers, to develop a comprehensive plan to address the client's impulsive behaviors.

Addressing Other Choices:

Choice B: Maintaining contact with family members is important, but it is not the priority intervention in the acute phase of mania.

Choice C: Discouraging inappropriate sexual expression is necessary, but it does not address the immediate risk of harm posed by impulsive behavior.

Choice D: Controlling loud and vulgar language is important for maintaining a therapeutic environment, but it is not the priority intervention in terms of safety.

Choice A rationale:

Administering an anti-anxiety medication may not be the most appropriate first action. While medication can help to reduce anxiety, it does not address the underlying issue of suicidal ideation. In some cases, medications can even increase the risk of suicide, especially in the first few weeks of treatment.

Instituting mouth checks to assure the medication is swallowed is not a standard practice in this situation. It is more important to focus on ensuring the client's safety and providing emotional support.

Choice B rationale:

Informing the provider about the client's statement is important, but it is not the first action that the nurse should take. The priority is to ensure the client's immediate safety.

The provider can be informed after the client has been stabilized and is no longer at immediate risk of harm.

Choice C rationale:

Assuring that a staff member stays with the client at all times is the most important first step in ensuring the client's safety. This will help to prevent the client from acting on their suicidal thoughts and provide an opportunity for the nurse to assess the client's risk for suicide and intervene as needed.

It also allows the nurse to provide emotional support and reassurance to the client.

Choice D rationale:

Questioning the client about a suicide plan and method is important, but it should not be done until the client's safety has been ensured. Asking about a suicide plan can be triggering for some clients and may increase their risk of suicide.

It is important to approach this topic sensitively and only when the client is feeling safe and supported.

Choice A rationale:

Hemoglobin (Hgb) of 11 g/dL is slightly below the normal range for adult females (12-16 g/dL) but is not considered a critical value.

It may indicate mild anemia, which is common in bulimia nervosa due to factors such as poor nutrition and blood loss from self-induced vomiting. However, it would not typically be the most urgent finding requiring immediate intervention.

Choice B rationale:

Potassium of 2.8 mEq/L is significantly below the normal range (3.5-5.0 mEq/L) and is considered a critical value, indicating severe hypokalemia.

Hypokalemia is a potentially life-threatening electrolyte imbalance that can lead to cardiac arrhythmias, muscle weakness, respiratory failure, and even death.

It is a common complication of bulimia nervosa due to excessive vomiting and/or laxative abuse, which can lead to significant potassium loss.

Therefore, this finding would be the nurse's priority, necessitating immediate intervention to correct the hypokalemia and prevent potentially life-threatening complications.

Choice C rationale:

Serum chloride of 96 mEq/L is slightly below the normal range (98-106 mEq/L) but is not considered a critical value.

It may be associated with hypokalemia, as chloride and potassium are often lost together in conditions like bulimia nervosa.

However, it would not typically be the most urgent finding requiring immediate intervention.

Choice D rationale:

Serum amylase of 240 units/L is elevated above the normal range (30-110 units/L) but is not considered a critical value.

It may indicate inflammation of the pancreas (pancreatitis), which can be a complication of bulimia nervosa due to recurrent vomiting and/or alcohol abuse.

However, it would not typically be the most urgent finding requiring immediate intervention, especially in comparison to severe hypokalemia.

Choice A rationale:

Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.

Choice B rationale:

Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.

Choice D rationale:

Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.

Choice C rationale:

Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:

Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.

Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.

Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.

Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.

Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.

Choice A:

Patronizing and judgmental: Telling the client they "should work hard" implies they haven't been trying hard enough, which can be discouraging and make them feel judged.

Ignores client's concerns: It doesn't acknowledge the client's past difficulties with medication adherence, which are a valid concern.

Not collaborative: It establishes a power dynamic where the nurse dictates the schedule, rather than working together with the client to find a solution that fits their needs.

Choice B:

Dismissive: It minimizes the client's concerns and past experiences, suggesting they shouldn't worry about it.

Unrealistic: It offers false reassurance without addressing the underlying challenges the client has faced with adherence.

Not supportive: It doesn't provide any practical guidance or strategies to help the client improve their medication adherence.

Choice C:

Accusatory and confrontational: Asking "why" in this way can put the client on the defensive and make them feel blamed for their difficulties.

Not empathetic: It doesn't express understanding for the challenges the client may be facing with medication adherence.

Not productive: It focuses on the reasons for non-adherence rather than working towards finding solutions.

Choice D:

Collaborative: It involves the client in the decision-making process, empowering them to take ownership of their medication regimen.

Individualized: It recognizes that a one-size-fits-all approach doesn't work for medication adherence, and that tailoring the schedule to the client's preferences and lifestyle is essential.

Supportive: It offers to work together with the client, conveying a sense of partnership and support.

Solution-focused: It shifts the focus from past difficulties to finding practical strategies for success in the present.

Choice A rationale:

Increased water intake is not a specific teaching point for fluoxetine. While general hydration is important for overall health, it's not directly related to the medication's effectiveness or side effects.

Fluoxetine is not known to cause dehydration or require fluid intake beyond typical recommendations.

Focusing on water intake could potentially distract from more relevant education about the medication.

Choice B rationale:

Sedation and sleepiness are common side effects of fluoxetine, especially during the initial weeks of treatment.

It's important for the client to be aware of these potential side effects so they can make necessary adjustments to their activities, such as avoiding driving or operating machinery if drowsy.

Understanding that these side effects are expected can also help with adherence to treatment, as clients may be less likely to discontinue the medication if they know that the side effects are likely to subside over time.

Choice C rationale:

Fluoxetine can sometimes cause sexual side effects, such as decreased libido or difficulty achieving orgasm.

It's important for the client to be aware of this potential side effect, but it's not accurate to say that they will definitely notice an improvement in their sex drive.

Sexual side effects can be distressing and may impact treatment adherence, so open communication with the healthcare provider is essential if these issues arise.

Choice D rationale:

Fluoxetine can take several weeks, typically 4-6 weeks, to fully exert its therapeutic effects.

Expecting to feel better within 3-4 days could lead to disappointment and frustration if symptom improvement isn't immediately noticeable.

It's important for the client to understand that patience is needed while the medication takes effect.

Choice A rationale:

Impulsivity and impaired judgment: Giving away personal items and money is a hallmark sign of mania, reflecting the client's impulsivity and impaired judgment. This behavior can have significant financial and social consequences, leading to loss of possessions, strained relationships, and even legal problems.

Potential for exploitation: Clients in a manic state are vulnerable to exploitation due to their impaired judgment and heightened suggestibility. They may be easily persuaded to give away possessions or money to others who may take advantage of their condition.

Risk of self-harm: In severe cases, impulsive behavior can extend to self-harm or suicide attempts. It's crucial to assess the client's risk for self-harm and take appropriate precautions to ensure their safety.

Indicator of severity: Giving away possessions is often considered a more severe manifestation of mania compared to other symptoms like hostility or pacing. It suggests a greater degree of impulsivity and impaired judgment, necessitating prompt intervention.

Choice B rationale:

Hostility and irritability: While hostility and sarcasm towards staff can be challenging to manage, they are not typically considered a priority concern in bipolar mania. These behaviors can often be addressed through de-escalation techniques, setting clear boundaries, and consistent communication.

Choice C rationale:

Psychomotor agitation: Pacing is a common symptom of mania, reflecting increased energy and restlessness. While it can be disruptive, it doesn't necessarily pose an immediate risk to the client's safety or well-being.

Managing agitation: Strategies to manage agitation include providing a calm and structured environment, offering opportunities for physical activity, and using relaxation techniques.

Choice D rationale:

Flight of ideas: Flight of ideas, a rapid flow of speech with abrupt changes in topic, is a characteristic feature of mania. While it can be disruptive to communication, it's not typically considered a priority concern in terms of safety or risk management.

Addressing communication: Strategies to address flight of ideas include active listening, gently redirecting the conversation, and using techniques to slow down the pace of speech.

A rationale:

It validates the client's experience while gently establishing reality:

Acknowledges the client's reality: Saying "I know you hear the voices" directly acknowledges the client's experience and shows that the nurse believes them. This validation is crucial for establishing trust and rapport with the client.

Gently introduces reality: The phrase "but I do not" gently introduces the concept that the nurse does not share the same experience. This helps to ground the client in reality and can reduce anxiety associated with feeling isolated or misunderstood.

Avoids challenging or dismissing the client: It doesn't challenge the client's perception of reality, which could lead to defensiveness or withdrawal. Instead, it respectfully acknowledges their experience while also suggesting that there may be a different way to interpret those experiences.

Facilitates further assessment and intervention: By validating the client's experience, the nurse can create an opening for further assessment and intervention. This might include exploring the content of the voices, their frequency and intensity, and any associated distress or impairment.

Choice B rationale:

While assessing frequency is important, it's not the initial priority:

Focuses on frequency, not validation: Asking "How often do you hear the voices?" focuses on gathering information rather than validating the client's experience. It could be perceived as dismissive or challenging, potentially hindering rapportbuilding.

May increase anxiety: Focusing on the frequency of the hallucinations could inadvertently increase the client's anxiety and preoccupation with the voices.

Can be addressed later in the assessment: Once the nurse has established trust and rapport, they can then inquire about the frequency and other details of the hallucinations.

Choice C rationale:

Probing for content can be distressing and may reinforce the hallucinations:

Encourages focus on the voices: Asking "What are the voices telling you?" directly engages with the content of the hallucinations, which could reinforce their salience and intensity.

Potentially distressing: It could prompt the client to relive distressing content or feel pressured to share personal information before they're ready.

Best addressed in a therapeutic context: Exploring the content of hallucinations is often more appropriate within a therapeutic relationship where the client feels safe and supported.

Choice D rationale:

Dismissive and potentially invalidating:

Invalidates the client's experience: Stating "The voices are part of your illness" might come across as dismissive or minimizing the client's distress. It could make them feel like their experiences are not being taken seriously.

Potentially damaging to rapport: This response could damage trust and rapport, making it less likely that the client will engage in further assessment or treatment.

Overly simplistic explanation: It offers a simplistic explanation that may not resonate with the client's understanding of their experiences.

Choice A:

While this response is well-intentioned, it may not be the most therapeutic in this situation. It could be perceived as dismissive of the client's feelings and concerns. Clients with schizophrenia often have difficulty trusting others, and this response could reinforce the client's belief that they are being held against their will.

It's important to acknowledge the client's feelings and concerns, rather than simply stating that the healthcare team is there to help.

Choice B:

This response is the most therapeutic because it uses the technique of reflection. Reflection involves echoing back the client's feelings or thoughts, which can help them feel heard and understood. It can also encourage the client to elaborate on their concerns.

By reflecting the client's statement, the nurse validates their feelings and opens the door for further communication.

Choice C:

This response could be perceived as confrontational or challenging, which could further escalate the client's anxiety. It's generally more helpful to start with a more open-ended question or reflection.

Asking "why" questions can sometimes make people feel defensive or put on the spot.

Choice D:

While relaxation techniques can be helpful for some clients, this response is not appropriate in this situation. It minimizes the client's concerns and does not address their underlying feelings of fear and anxiety.

It's important to validate the client's feelings before suggesting coping strategies.

Choice A rationale:

Shellfish is generally safe for clients taking MAOIs. However, it's important to ensure shellfish is fresh and properly refrigerated to avoid tyramine buildup due to spoilage.

Some individuals with shellfish allergies may need to avoid it regardless of MAOI use.

Choice B rationale:

Milk and milk products are typically safe for clients taking MAOIs.

However, some aged cheeses, such as cheddar, Swiss, and Parmesan, can contain high levels of tyramine and should be avoided.

Choice C rationale:

Canned tuna is generally safe for clients taking MAOIs.

However, it's essential to check labels carefully, as some brands may contain added tyramine-rich ingredients like soy sauce or fermented flavorings.

Choice D rationale:

Aged cheeses contain high levels of tyramine, an amino acid that can interact with MAOIs and cause a hypertensive crisis.

This is a potentially life-threatening condition characterized by a sudden and severe increase in blood pressure.

It's crucial for clients taking MAOIs to avoid all aged cheeses, including cheddar, Swiss, Parmesan, blue cheese, feta, and others.