select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior select one that does not apply
Logo

Nursing Elites

HESI LPN

HESI Mental Health 2023

1. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.

Correct answer: B

Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.

2. A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?

Correct answer: B

Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.

3. A nurse working on a mental health unit receives a community call from a person who is tearful and states, 'I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days.' The nurse should initiate a referral based on which assessment?

Correct answer: B

Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.

4. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

Correct answer: A

Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

5. A 25-year-old female client has been particularly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, 'Please let me go! I must leave because the secret police are after me.' Which response is best for the nurse to make?

Correct answer: D

Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance. Choice A is incorrect because directly denying the client's belief may escalate the situation. Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue. Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike Choice D which offers both.

Similar Questions

What information should the nurse include in the client's teaching about starting a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder?
When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?
A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago, lost his job four months ago, and suffered a breakup of his current relationship last week. What is the most likely source of this client's current feelings of depression?
A client with obsessive-compulsive disorder (OCD) spends several hours a day arranging and rearranging items in their room. What is the most therapeutic nursing intervention?
At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses