a client with a history of bipolar disorder is exhibiting symptoms of mania which intervention is most appropriate for the nurse to implement
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Nursing Elites

HESI RN

Mental Health HESI Quizlet

1. A client with a history of bipolar disorder is exhibiting symptoms of mania. Which intervention is most appropriate for the nurse to implement?

Correct answer: C

Rationale: When a client with bipolar disorder is experiencing symptoms of mania, the most appropriate intervention for the nurse is to limit stimulation and set firm limits on behavior. This approach helps in managing the manic episode by preventing further escalation. Encouraging participation in group therapy (Choice A) may not be effective during the acute phase of mania, as the client may have difficulty focusing or following group discussions. Providing a calm and structured environment (Choice B) is beneficial, but setting firm limits is crucial to managing the impulsivity and risky behaviors associated with mania. Promoting self-care practices (Choice D) is important, but during a manic episode, setting limits and reducing stimuli take precedence over hygiene practices.

2. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

Correct answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

3. A client is being treated for generalized anxiety disorder (GAD) and is prescribed an SSRI. Which side effect should the nurse educate the client about?

Correct answer: C

Rationale: The correct answer is C: Insomnia. Insomnia is a common side effect of SSRIs, including those used to treat generalized anxiety disorder (GAD). Educating the client about potential side effects like insomnia is crucial for managing expectations and promoting treatment adherence. Weight loss (choice A) is less common with SSRIs and might not be a primary concern for a client with GAD. Increased appetite (choice B) is also less likely with SSRIs. Dry mouth (choice D) is a side effect more commonly associated with other classes of medications, such as anticholinergics, rather than SSRIs.

4. A client with anorexia nervosa has a body mass index (BMI) of 16.5 and has been diagnosed with bradycardia. Which of the following findings should the RN be most concerned about?

Correct answer: D

Rationale: In a client with anorexia nervosa and bradycardia, monitoring for ECG changes is crucial as these changes may indicate potentially life-threatening cardiac complications. While other findings like low body temperature, bradycardia, and serum potassium levels are concerning, ECG changes specifically reflect the impact of bradycardia on the heart's electrical activity and should be the priority for the nurse to assess and address.

5. During the admission assessment, a female client requests that her husband be allowed to stay in the room. When the RN notes a discrepancy between the client’s verbal and nonverbal communication, what action should the RN take?

Correct answer: A

Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client’s communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client’s husband to interpret the discrepancy (Choice B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (Choice C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (Choice D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.

Similar Questions

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A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?
A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?
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