The nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, 'You can't do this to me. Do you know who I am?' Which is the priority nursing action in this situation?

Correct Answer: B

Rationale: The correct answer is B: Take the child swimming at the facility's pool. This is the priority action because the client is exhibiting signs of agitation and potential aggression, and physical activity like swimming can help release pent-up energy and reduce stress. It can also serve as a distraction and help de-escalate the situation. A: Asking the child about their feelings may not be effective in this moment of agitation. C: Establishing a behavioral contract requires a calm and cooperative state from the client, which is not the case currently. D: Administering an anxiolytic medication should not be the initial response unless the client's behavior becomes a safety concern and other interventions have failed.

Correct Answer: D

Rationale: The correct answer is D, High. The adolescent expressing a desire to die, seeking revenge, and having a specific suicide plan indicate a high suicide risk. The adolescent's plan is detailed and connected to a past traumatic event, increasing the likelihood of intent to carry it out. The reference to the father's actions suggests a deep emotional impact and potential for impulsive behavior. Choices A, B, and C are incorrect because the adolescent's statements demonstrate clear indicators of high suicide risk, requiring immediate intervention to ensure safety.

Correct Answer: A

Rationale: The correct answer is A because the assessment findings of being negative, hostile, and spiteful toward parents, and blaming others for misbehavior align with Oppositional Defiant Disorder (ODD) criteria. This behavior pattern is a key characteristic of ODD, where individuals often display defiance and hostility towards authority figures. Choice B describes symptoms of Tourette syndrome, not ODD. Choice C describes conduct disorder behaviors, not specific to ODD. Choice D is unrelated to ODD symptoms.

Correct Answer: C

Rationale: The correct answer is C because it specifically asks about the patient's difficulty in walking a quarter of a mile, which assesses their capacity for functional activities. This question focuses on a specific distance and activity, providing a clear indication of the patient's ability to participate in a common daily task. Choice A is too general and does not specify a distance or activity, making it less effective in assessing functional capacity. Choice B focuses on the effect of an assistive device rather than the patient's actual ability to perform the activity. Choice D asks about going up and down stairs, which is not as indicative of overall functional capacity compared to walking a quarter of a mile.

Correct Answer: A

Rationale: The correct answer is A. Sitting with the arm in a horizontal, supported position at heart level is recommended for consistent blood pressure measurements because it helps reduce errors due to gravitational effects. Placing the arm at heart level minimizes the hydrostatic pressure changes, ensuring accurate readings. This position also allows for proper cuff placement and comfortable arm support, leading to more reliable results. Summary: Choice B (Supine position with arm resting comfortably on the chest) may lead to inaccurate readings due to the arm position not being at heart level. Choice C (Sitting on the couch with arm resting comfortably by the side) lacks the necessary arm support and heart level positioning, leading to potential errors. Choice D (Standing with arm by side and cuff positioned at heart level) may result in fluctuating readings due to the effect of gravity on blood pressure when standing.