A client with bipolar disorder who became hyperactive after discontinuing lithium has not eaten or
slept for 3 days. Mood and behavior are labile, changing rapidly from playful to aggressive.
If the
client threatens to hit another client or a staff member, which response would constitute an
appropriate intervention?
a. "Stop that! No one did anything to provoke an attack by you.".
b. "If you try that one more time, you will be placed in seclusion immediately.".
c. "Do not hit me/him/her. If you are unable to control yourself, we will help you.".
d. "You know we will not let you hit anyone! Why do you continue such
self-defeating behavior?"
C
When the client is unable to control his or her behavior and violates or threatens to violate the rights
of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple,
concrete terms. Option A does not offer appropriate assistance to the client. Option B threatens the
client with seclusion as punishment. Option D asks a rhetorical question.
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A nurse has completed a family pedigree on a patient with a known autosomal dominant inheritance disorder. No one else in the family has been affected by this disorder. How does the nurse explain this finding to the patient?
A. Genetic variation occurred via a mutation. B. Information about the family is incorrect. C. The patient is not biologically related to the family. D. The patient's diagnosis must be incorrect.
A nurse is developing an international health project on delivery of prenatal care to low-resourced communities. Which of the following principles guides the nurse's planning?
1. Nurses are in the best position to decide what the community needs. 2. The project is dependent on political influences or partisanship. 3. Short- and long-term goals contribute to the sustainability of the project. 4. Local community leaders are best to oversee the project.
Which of the following measures can help prevent or reduce the risk for fire and burns?
A) have a fire extinguisher in the house B) avoid using flammable liquids C) only use extension and electrical cords that are in great shape D) all of the above
J.B. asks how he will be able to let the nurses know what he needs if he cannot talk. How will
you respond? What will be an ideal response?