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ISPN考试模拟试题(439)

Question:

A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially

1. Encourage the client to stay in his room. 

2. Seclude the client at the first sign of agitation. 

3. Tell the client to seek out staff when feeling agitated. 

4. Instruct the client to ask for medication when agitated.


 

Initially, the nurse would tell the client to seek out staff when feeling agitated or upset to prevent violent episodes. Doing so helps the client to redirect negative feelings in an appropriate manner (eg, talking). Encouraging the client to stay in his room is inappropriate because it does not help the client to deal with his feelings. Secluding the client at the first sign of agitation is not indicated and may be perceived by the client as punishment. Instructing theclient to ask for medication when agitated would not be the initial course of action. The nurse would interact with the client and direct the client to an activity to decrease his anxiety before intervening with any required medication. 

CN: Psychosocial integrity; CL: Synthesize

Answer:3

 

翻译

问题:

患有双相情感障碍、躁狂症的病人会有很多夸张的想法,而且很容易激动。为了防止有害行为,护士首先应该做以下哪一项?

1.鼓励病人待在房间里。

2.一有激动的迹象就把病人隔离起来。

3.告诉病人在感到不安时找工作人员。

4.当病人情绪激动时,应指示病人要求用药。

 

答案:3

最初,护士会告诉病人在感到焦虑或不安时找工作人员,以防止暴力事件的发生。这样做有助于病人以适当的方式重新引导负面情绪(如交谈)。鼓励病人呆在房间里是不合适的,因为这无助于病人处理自己的感受。在病人初有躁动迹象时不应将其隔离,病人可能认为这是一种惩罚。当病人情绪激动时,指导病人要求服药并不是最初的行动方针。护士会与病人互动,指导病人进行一项活动,以减轻他的焦虑,然后再进行所需的药物干预。

CN:心理社会完整性;CL:综合性

小编寄语:Life is to live beautifully and walk sonorously.人生,就要活得漂亮,走得铿锵。

时间:2021/1/13 10:47:49
 
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