HESI COMPREHENSION EXAM 4. QUESTIONS AND ANSWERS. WITH RATIONALE

1.A client in a manic state emerges from her room and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. The priority nursing action is to: A. Ask the client to go to her room and to change her clothes B. Tell the client firmly that burlesque shows are not allowed in the nursing unit C. Tell the client that her bathroom privileges are being suspended because of her behavior D. Quietly and firmly assist the client to her room and help her dress in appropriate clothes Correct Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client’s bathroom privileges because of behavior, having the client change her clothes and telling the client that burlesque shows are not allowed in the nursing unit will all increase the client’s anxiety.