A client with bipolar disorder is commanding another client to "Get me that book; take this other
stuff out of here," and so forth. The nurse wants to interrupt this behavior without entering into a
power struggle with the client.
The best approach would be to use
a. humor: "How much are you paying servants these days?"
b. distraction: "Let's go to the dining room for a snack.".
c. limit setting: "You must stop ordering other clients around.".
d. honest feedback: "Your behavior is annoying other clients.".
B
The distractibility characteristic of manic episodes can assist the nurse to direct the client toward
more appropriate, constructive activities without entering into power struggles. Humor usually
backfires by either encouraging the client or inciting anger. Limit setting and honest feedback may
seem heavy handed to a labile client and may incite anger.
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During skin inspection of a client, a nurse observes lesions with wavy borders that are widespread across the client's chest. Which descriptors should the nurse use to document these observations?
a. Clustered and annular b. Linear and circinate c. Diffuse and serpiginous d. Coalesced and circumscribed
A nurse is caring for a newborn 1 day after delivery. The infant's mother used betaxolol during pregnancy. The nurse will expect to monitor this infant for which condition?
a. Hyperglycemia b. Hyperthyroidism c. Respiratory distress d. Tachycardia
What is one advantage of problem-intervention-evaluation (PIE) charting?
a. Focuses on a complete list of client problems b. Assesses the client in a comprehensive manner c. Documents the planning portion of the client's care d. Establishes an ongoing plan of care for the client
Signs or symptoms that may be the result of abuse include
A) a toothache. B) bruises. C) dry skin. D) unmatched clothing.