the manic state.
Such activities may lead
to increased frustrations and anxiety for
the client. Tetherball is an exercise that
uses the large muscle groups of the body
and is a great way to expend the
increased energy this client is
experiencing.
15. A woman comes into the emergency room in
a severe state of anxiety after a car accident.
The most important nursing intervention is to:
a. Remain with the client
b. Put the client in a quiet room
c. Teach the client deep breathing
d. Encourage the client to talk about her
Feelings and concerns
16. A male client with delirium becomes agitated
and confused in his room at night. The best
initial intervention by the nurse is to:
a. Use a night light and turn off the television
b. Keep the television and a soft light on
during the night
c. Move the client next to the nurse station
d. Play soft music during the night, and
maintain a well lit room
17. A nurse is collecting data on a client who is
actively hallucinating. Which of the following
nursing statements would be most
therapeutic at this time?
a. “I talked to the voices you’re hearing and
they wont hurt you now”
b. “I can hear the voice and she wants you
to come to dinner”
c. “sometimes people hear things or voices
other can’t hear”
d. “I know you feel ‘they are out to get you’
but it’s not true
18. A nurse is caring for a client who has been
treated with long term anti-psychotic
medication. As part of the nursing care plan,
the nurse monitors for tardive dyskinesia
(TD). In the event that TD occurs, the nurse
would most likely to observe:
a. Abnormal movements and involuntary
movements of the mouth, tongue and
face
b. Abnormal breathing through the nostrils
c. Severe headache, flushing, tremor and
ataxia
d. Severe hypertension, migraine headache,
and “marbles in the mouth” syndrome
St. Louis Review Center, Inc-Davao Tel. no. (082) 224-2515 or 222-8732
15. Answer A
If a client is left alone with severe anxiety,
he or she may feel abandoned and
become overwhelmed. Placing the client
in a quiet room is also indicated, but the
nurse must stay with the client. It is not
possible to teach the client deep
breathing until a the anxiety decreases.
Encouraging the client to discuss
concerns and feelings would not take
place until the anxiety has increased.
16. Answer A
It is important to provide a consistent daily
routine and a low stimulating environment
when the client is agitated and confused.
Noise levels including a radio and
televisionmay add to the confusion and
disorientation. Moving the client next to
the nurses’ station is not the initial action.
17. Answer C
It is important to the nurse to reinforce
reality with the client. Options A, B and D
do not reinforce reality but rather the
hallucination that the voices are real.
18. Answer A
Tardive dyskinesia is a severe reaction
associated with the long term use of
antipsychotic medication. The clinical
manifestation are abnormal movements
(dyskinesia) and involuntary movements
of the mouth, tongue and face. In its more
severe form, tardive dyskinesia involves
the fingers, arms, trunk and respiratory
muscles. When this occurs, the
medication is discontinued.
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