Question

A nurse is caring for an adult client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Document the client's behavior every 15 min while in seclusion.

Rationale :

🔵 When a client is placed in seclusion, strict legal and ethical guidelines require continuous monitoring and documentation of behavior at least every 15 minutes.

🔵 Frequent documentation ensures the intervention remains justified, necessary, and time-limited, protecting the client’s rights and safety.

🔵 Ongoing assessment allows the nurse to evaluate for physical distress, psychological status, and readiness for release.

🔵 Seclusion is considered a last-resort safety measure, so accurate records demonstrate compliance with regulatory standards.

🔵 Proper monitoring reduces risk of injury, dehydration, or medical complications while maintaining therapeutic accountability.

Incorrect Options

Request that the provider assess the client within 8 hr.

A provider must evaluate the client within a much shorter timeframe (usually within 1 hour for adults). Waiting 8 hours would violate safety regulations.

Discontinue the seclusion if the client requests it.

Seclusion is discontinued based on behavioral criteria and safety assessment, not simply on request. The client must demonstrate regained behavioral control.

Request a PRN prescription for future seclusion.

Seclusion cannot be prescribed as a PRN measure. Each episode requires a time-limited, specific provider order based on current behavior.

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Answer 2

Correct Answers:

Identify the client's feelings underlying the delusions.

Rationale :

🟣 When caring for a client with delusions, the nurse should avoid validating or confronting the false belief and instead focus on the emotional experience behind it.

🟣 Identifying the client’s underlying feelings, such as fear, anxiety, or insecurity, promotes therapeutic communication without reinforcing the delusion.

🟣 This approach maintains reality orientation while preserving trust in the nurse–client relationship.

🟣 Addressing emotions helps reduce distress and may decrease the intensity of delusional thinking.

🟣 Focusing on feelings supports long-term coping and stabilizes the therapeutic alliance.

Incorrect Options

Tell the client that the delusion is not real.

Directly confronting a delusion can increase defensiveness and mistrust. It may damage rapport and escalate agitation.

Reinforce the delusion to gain the client's cooperation.

Reinforcing a delusion strengthens false beliefs and impairs reality testing. This approach is unethical and nontherapeutic.

Help the client to ignore events that trigger delusions.

Simply telling the client to ignore triggers minimizes their experience. Effective care involves processing emotions rather than dismissing them.

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Answer 3

Correct Answers:

Sharpened perceptions

Rationale :

🟡 Mild anxiety is characterized by heightened alertness and increased perceptual field, allowing the client to focus effectively.

🟡 In this stage, the client experiences sharpened perceptions, improved problem-solving ability, and enhanced learning capacity.

🟡 Mild anxiety can actually be adaptive and motivating, improving performance in certain situations.

🟡 Unlike moderate or severe anxiety, mild anxiety does not significantly impair concentration or cause overwhelming distress.

🟡 Recognizing this stage helps the nurse tailor appropriate coping interventions before escalation occurs.

Incorrect Options

Selective inattention

Selective inattention occurs in moderate anxiety, when the perceptual field narrows. It is not typical of mild anxiety.

Urinary frequency

Urinary frequency is more commonly associated with moderate to severe anxiety due to increased autonomic stimulation.

Voice tremors

Voice tremors are typically seen in higher levels of anxiety, reflecting increased sympathetic nervous system activation.

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Answer 4

Correct Answers:

The client has increased social engagement.

Rationale :

🟠 In clients with major depressive disorder (MDD), improvement in social engagement reflects enhanced mood, motivation, and participation in life activities.

🟠 Depression commonly causes withdrawal, anhedonia, and isolation, so re-engaging socially indicates therapeutic progress.

🟠 Increased interaction demonstrates improved energy level, interest, and emotional responsiveness, which are core treatment goals.

🟠 Social participation also suggests better adherence to medication, therapy sessions, and behavioral activation strategies.

🟠 Positive behavioral changes like this are measurable indicators that the client is actively following and benefiting from the treatment plan.

Incorrect Options

The client verbalizes difficulty coping.

Expressing difficulty coping may indicate ongoing depressive symptoms. While verbalization can be therapeutic, it does not necessarily reflect improved adherence.

The client frequently seeks reassurance.

Frequent reassurance-seeking may indicate persistent anxiety or insecurity. It does not directly show progress in managing depressive symptoms independently.

The client has hygiene deficiencies.

Poor hygiene is commonly associated with worsening depression. It indicates impaired motivation and reduced adherence to self-care expectations.

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Answer 5

Correct Answers:

A residential rehabilitation program

Rationale :

🔵 A client with severe hypertension and alcohol use disorder requiring detoxification needs a medically supervised residential rehabilitation program.

🔵 Detoxification from alcohol can cause life-threatening complications such as seizures, delirium tremens, and autonomic instability, requiring 24-hour monitoring.

🔵 Severe hypertension further increases the risk of cardiovascular complications during withdrawal.

🔵 Residential programs provide structured medical stabilization, medication management, and intensive therapy.

🔵 This level of care ensures safety during detox while initiating comprehensive addiction treatment.

Incorrect Options

Intensive outpatient therapy

Intensive outpatient programs do not provide 24-hour medical supervision. They are inappropriate for clients requiring acute detoxification.

Alcoholics Anonymous

AA is a peer-support group and does not provide medical detox services. It is helpful after stabilization, not during acute withdrawal.

A halfway house

Halfway houses provide transitional living support but do not offer medical detoxification or acute care.

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Answer 6

Correct Answers:

Hallucinations
Decreased attention span
Change in level of consciousness

Rationale :

🟢 Hallucinations

🟢 Delirium is characterized by an acute disturbance in attention and cognition, often accompanied by perceptual disturbances such as visual hallucinations.

🟢 These hallucinations typically have a rapid onset and fluctuate throughout the day, distinguishing delirium from chronic psychotic disorders.

🟢 Visual hallucinations are especially common in metabolic imbalances, infections, or substance withdrawal, which are frequent causes of delirium.

🟢 The sudden appearance of hallucinations in a previously stable client strongly suggests an organic etiology.

🟢 Identifying hallucinations early allows prompt investigation of the underlying medical cause.

🟢 Decreased attention span

🟢 A hallmark feature of delirium is impaired attention, meaning the client cannot sustain focus or follow conversations.

🟢 Clients may be easily distracted, unable to complete tasks, or unable to maintain coherent thought processes.

🟢 This deficit reflects acute disruption of cerebral function, often reversible with treatment of the underlying condition.

🟢 Decreased attention differentiates delirium from primary psychiatric conditions like depression.

🟢 Careful assessment of attention is essential when evaluating sudden cognitive changes.

🟢 Change in level of consciousness

🟢 Delirium frequently involves a fluctuating level of consciousness, ranging from hyperalert agitation to lethargy.

🟢 Clients may appear drowsy, confused, or intermittently lucid during the same day.

🟢 This waxing-and-waning pattern is a defining feature of delirium.

🟢 Altered consciousness indicates an acute neurological or systemic disturbance requiring urgent medical evaluation.

🟢 Recognizing this change allows timely intervention to prevent complications.

Incorrect Options

Akathisia

Akathisia is a medication-induced movement disorder characterized by inner restlessness. It is not a defining feature of delirium.

Aphasia

Aphasia involves impaired language ability due to neurological injury such as stroke. It is not a primary characteristic of delirium.

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Answer 7

Correct Answers:

"You're afraid you have caused physical injury to yourself?"

Rationale :

🟡 This response uses reflection, a therapeutic communication technique that helps the client explore underlying fears and emotions.

🟡 Clients with anorexia nervosa often experience intense guilt, distorted body image, and fear of physical consequences, making emotional validation essential.

🟡 Reflecting the concern encourages the adolescent to elaborate without providing false reassurance or dismissing the worry.

🟡 It maintains the nurse–client relationship by demonstrating empathy and avoiding deflection.

🟡 Addressing feelings first promotes trust and allows further assessment of the client’s insight and anxiety.

Incorrect Options

"You should ask your provider that question."

This response deflects responsibility and shuts down communication. It fails to address the client’s emotional concern.

"I wouldn't worry about any permanent damage you might have caused right now."

This statement offers false reassurance and minimizes the client’s fear. It dismisses the seriousness of the client’s concern.

"Why do you feel like you have damaged your body?"

Although open-ended, this question may feel accusatory. It does not provide emotional validation before exploring reasoning.

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Answer 8

Correct Answers:

"This therapy will help me use specific body postures to achieve balance."

Rationale :

🔵 Biofeedback therapy uses electronic monitoring devices to help clients gain awareness and control over physiological processes, such as heart rate and blood pressure.

🔵 Clients learn to recognize subtle body responses to stress through real-time feedback from monitoring equipment.

🔵 This increased awareness allows the client to consciously practice techniques to regulate autonomic nervous system responses.

🔵 Biofeedback is commonly used for conditions like hypertension, migraines, anxiety, and chronic pain.

🔵 Understanding that the therapy involves recognizing internal physiological changes demonstrates accurate comprehension.

Incorrect Options

"This therapy will help me use specific body postures to achieve balance."

This statement describes yoga or balance training, not biofeedback. Biofeedback focuses on physiological monitoring.

"This therapy will improve my range of motion."

Improving range of motion is associated with physical therapy. Biofeedback does not directly target musculoskeletal flexibility.

"This therapy will help me to concentrate on soothing images."

Concentrating on soothing images is a relaxation or guided imagery technique. Biofeedback involves monitoring body functions through equipment.

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Answer 9

Correct Answers:

The client refuses to drink fluids.

Rationale :

🔴 Clients experiencing mania often exhibit hyperactivity, decreased need for sleep, and poor judgment, placing them at risk for dehydration.

🔴 Refusal to drink fluids can quickly lead to electrolyte imbalance, hypotension, and acute kidney injury, making this a physiologic priority.

🔴 According to the priority framework (ABCs and physiologic stability first), hydration status must be addressed before behavioral concerns.

🔴 Manic clients frequently neglect nutrition and hydration due to distractibility and excessive activity.

🔴 Immediate intervention prevents medical complications and supports overall stabilization.

Incorrect Options

The client slept 4 hr last night.

Decreased sleep is common in mania and expected. It is concerning but not immediately life-threatening.

The client refuses to take a shower.

Poor hygiene is typical during mania due to distractibility. It does not present an urgent medical risk.

The client ate half of the provided snack.

Reduced intake is common but less critical than complete refusal of fluids. Hydration is the greater priority.

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Answer 10

Correct Answers:

Ensure the client signs the form voluntarily.

Rationale :

🟢 When acting as a client advocate during informed consent, the nurse’s role is to verify that consent is given voluntarily and without coercion.

🟢 The provider is responsible for explaining risks, benefits, purpose, and alternatives of the procedure.

🟢 The nurse ensures the client understands that signing is based on free choice and informed decision-making.

🟢 Advocacy includes confirming the client is competent and not under pressure from others.

🟢 Protecting the client’s autonomy upholds legal and ethical standards of practice.

Incorrect Options

Explain the benefits of the procedure to the client.

Explaining benefits is the provider’s responsibility. The nurse should not provide detailed procedural explanations beyond clarification.

Describe alternatives to the procedure to the client.

Discussion of alternatives must come from the provider. The nurse reinforces understanding but does not initiate this discussion.

Inform the client of the purpose of vagus nerve stimulation.

The provider must explain the purpose before consent. The nurse verifies understanding rather than delivering the full explanation.

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QLexNursing

1 :
A nurse is caring for an adult client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?

Incorrect Options

2 :
A nurse is caring for a client who has schizophrenia and is experiencing frequent delusions. Which of the following strategies should the nurse use when caring for the client?

Incorrect Options

3 :
A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Incorrect Options

4 :
A nurse is evaluating a client who has major depressive disorder and their ability to adhere to the treatment plan. Which of the following findings is a positive indicator of adherence?

Incorrect Options

5 :
A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?

Incorrect Options

7 :
A nurse is caring for an adolescent client who has anorexia nervosa. The client asks the nurse, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?

8 :
A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?

Incorrect Options

9 :
A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?

Incorrect Options

10 :
A nurse is assisting in obtaining informed consent from a client who is scheduled for vagus nerve stimulation. Which of the following actions should the nurse take to act as a client advocate?

QLexNursing

1 : A nurse is caring for an adult client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?

Incorrect Options

2 : A nurse is caring for a client who has schizophrenia and is experiencing frequent delusions. Which of the following strategies should the nurse use when caring for the client?

Incorrect Options

3 : A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Incorrect Options

4 : A nurse is evaluating a client who has major depressive disorder and their ability to adhere to the treatment plan. Which of the following findings is a positive indicator of adherence?

Incorrect Options

5 : A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?

Incorrect Options

7 : A nurse is caring for an adolescent client who has anorexia nervosa. The client asks the nurse, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?

8 : A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?

Incorrect Options

9 : A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?

Incorrect Options

10 : A nurse is assisting in obtaining informed consent from a client who is scheduled for vagus nerve stimulation. Which of the following actions should the nurse take to act as a client advocate?

1 :
A nurse is caring for an adult client who is experiencing mania and is placed in seclusion due to escalating behavior. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who has schizophrenia and is experiencing frequent delusions. Which of the following strategies should the nurse use when caring for the client?

3 :
A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

4 :
A nurse is evaluating a client who has major depressive disorder and their ability to adhere to the treatment plan. Which of the following findings is a positive indicator of adherence?

5 :
A nurse in an emergency department is preparing to discharge a client who has severe hypertension and requires detoxification for alcohol use disorder. The nurse should recommend a referral to which of the following resources?

7 :
A nurse is caring for an adolescent client who has anorexia nervosa. The client asks the nurse, "Have I done any permanent damage to my body?" Which of the following responses should the nurse make?

8 :
A nurse is teaching a client about biofeedback therapy. Which of the following client statements indicates an understanding of the teaching?

9 :
A nurse is assessing a client who has bipolar disorder and is experiencing mania. Which of the following findings is the priority for the nurse to report to the provider?

10 :
A nurse is assisting in obtaining informed consent from a client who is scheduled for vagus nerve stimulation. Which of the following actions should the nurse take to act as a client advocate?