NR-326 Mental Health Nursing - Set 2 - Part 3

Correct Answer: This is a high-risk window requiring continued close monitoring

The first weeks of treatment, any dose increase, and the period right after discharge each raise risk, and this client is inside all three. Monitoring is maintained and the safety plan is completed. Option a is incorrect because precautions are withdrawn on the basis of a documented reassessment, never on the basis of a discharge date. Removing them now would strip supervision at the highest-risk transition. Option c is incorrect because visible activity says nothing about whether hopelessness has lifted. Energy returns first, which is why the client must still be asked directly rather than judged by appearance. Option d is incorrect because leaving the follow-up appointment to the client is the standard that current practice abandoned. The appointment is booked before discharge, ideally within a week, and confirmed with the family.

Correct Answer: The client who brightened suddenly after weeks of despair

An abrupt lift in mood after prolonged severe depression is a warning sign rather than recovery, because the client may have settled on a decision. That client is seen first and reassessed for risk. Option b is incorrect because tearfulness during a family visit is congruent with the admitting diagnosis. Distress that matches the clinical picture is expected, so this client can be seen after the unexpected change is investigated. Option c is incorrect because poor intake and withdrawal to bed are vegetative features already known to the team. They need attention during the shift, yet they represent no change from the documented baseline. Option d is incorrect because interest in discharge planning shows future orientation, which belongs on the protective side. The nurse follows up on it during rounds instead of treating it as the shift's most urgent finding.

Correct Answer: "I see how frightening that thought is for you."

Acknowledging the fear behind the ritual builds the trust this deeply ashamed client needs. The nurse neither argues with the belief nor blocks the washing early on, since the ritual is his only defense. Option a is incorrect because arguing with the logic of an obsession never dislodges it. Debate leaves the client feeling ridiculed and less willing to talk, and the shame around these symptoms already delays help seeking. Option b is incorrect because abruptly forbidding a ritual early in treatment strips away the client's only protection and drives anxiety toward panic. Limits are set gradually, with the team, as alternative coping develops. Option c is incorrect because invoking what the family wants adds guilt to an already distressing symptom. Compulsions are not under voluntary control, so an appeal to stop worrying asks for something he cannot deliver.

Correct Answer: Quietly escort the client to a solitary activity

Removing the client quietly protects the group and spares a public confrontation that would escalate everyone. A solitary walk or another gross motor task burns the same energy without the audience mania feeds on. Option a is incorrect because asking peers to ignore the behavior leaves them exposed to it. Other clients cannot consent to being taken over or touched, and the manic client stays in a setting that overloads him. Option c is incorrect because a public explanation strips the client's dignity in front of the whole unit. Once euthymic he will remember the scene with shame, and the group still has to continue meanwhile. Option d is incorrect because a firm order delivered in front of peers invites a power struggle the nurse cannot win. Manic clients argue on speed alone, and the confrontation itself adds stimulation.

Correct Answer: Rising heart rate with increasing difficulty rousing him

A climbing pulse together with a client who is harder to wake signals impending exhaustion and cardiovascular collapse. This is the physiologic emergency inside mania, so the nurse escalates and begins fluids and monitoring. Option b is incorrect because rapid unstoppable speech is an expected feature of the episode itself. The nurse documents it and keeps interactions short, but nothing about it threatens the client's circulation this morning. Option c is incorrect because late night calls illustrate the decreased need for sleep already known to be present. Restricting phone access addresses it, and that plan can wait until the team meets. Option d is incorrect because skipping a large group meeting is appropriate rather than alarming. Group programming escalates mania, so the nurse would not push attendance and would offer a solitary activity instead.

Correct Answer: Appeared suddenly calm after weeks of despair

An unexplained lift in mood after prolonged severe depression often means the client has reached a decision and feels relief. Risk rises rather than falls, so the nurse reassesses and alerts the team. Option a is incorrect because early waking is an expected vegetative feature of the illness itself. It belongs in the ongoing assessment and is documented, yet it signals no change in acute danger. Option b is incorrect because partial participation still shows engagement with the milieu. Skipping one group while coming to a meal is worth documenting but does not shift the acute risk picture. Option d is incorrect because interest in visitors points toward connection and future orientation. Those are protective rather than alarming, and the nurse encourages the contact instead of treating it as a red flag.

Correct Answer: Agoraphobia involving multiple avoided situations

Agoraphobia is marked fear of two or more situations such as public transport, standing in line, or being outside the home alone, because escape or help might be unavailable if panic symptoms arrive. Option b is incorrect because an animal phobia attaches to one creature and is avoided easily without shrinking daily life. This client avoids a whole class of everyday settings tied to escape, not a single object. Option c is incorrect because the driving fear in social anxiety is humiliation in front of others. Standing in a checkout line would be avoided for fear of judgment, not for fear of being unable to leave. Option d is incorrect because separation anxiety centers on losing an attachment figure rather than on the setting itself. Her sister functions as a safety companion here, which is a different use of another person entirely.

Correct Answer: The second client needs the higher level of observation

Plan specificity, access to means, living alone, and a recent attempt stack risk factors with no protective counterweight. That combination is the higher acuity presentation and calls for constant observation on admission. Option a is incorrect because equating the two ignores every variable that grades acuity. Passive ideation with a partner at home sits well below a concrete plan combined with isolation and a recent attempt. Option b is incorrect because it reverses the relationship between the two presentations. Wishing not to wake up is passive ideation, and a live-in partner supplies support that lowers rather than raises the assessed level. Option c is incorrect because dismissing both admissions overlooks a client who has already acted once and now holds a worked-out plan. A prior attempt alone justifies the highest available observation level on the first night.

Correct Answer: The image is an obsession, scrubbing a compulsion

Obsessions are intrusive unwanted thoughts, urges, or images that raise anxiety. Compulsions are the repetitive acts performed to bring that anxiety down, and the brief relief they give is what keeps them going. Option a is incorrect because a mental image is not an act. Compulsions are behaviors or mental rituals the person feels driven to carry out, while the intrusive picture arrives on its own and is unwanted. Option b is incorrect because the labels are swapped. Scrubbing is the deliberate repeated behavior that lowers distress, and the germ picture is the intrusive thought that created the distress in the first place. Option d is incorrect because calling both obsessions leaves out the behavior entirely. Cleaning the counters repeatedly is an observable action driven by the thought, which places it firmly on the compulsion side.

Correct Answer: Risk for injury related to physical exhaustion

Days of continuous motion without sleep or food drive the client toward dehydration, exhaustion, and cardiovascular collapse. Physiological survival outranks every psychosocial goal, so the nurse targets rest, fluids, and calories now. Option a is incorrect because coping work requires insight the client cannot access mid episode. Teaching about stress management will be wasted while the body is running down, and it addresses nothing life threatening today. Option c is incorrect because intrusive behavior disrupts the milieu and does matter, yet other clients can be protected by staff while the manic client's own heart, fluid balance, and rest deteriorate unattended. Option d is incorrect because grandiose thinking resolves as the episode is treated and cannot be argued away now. Naming it as the first priority skips the physical deterioration that is already measurable in weight and vital signs.