Question on a Mental Health exam today. Please help.

Nurses LPN/LVN

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Today we had the final exam in Mental Health. One of the questions that is bothering me until now concerns:

what a nurse's first reaction should be when a client who is having a manic episode comes up to the nurse, hugs and kisses her on the mouth. She is totally taken by surprise.

The options were something like this:

A. Ask the patient what the meaning of this action is.

B. Tell the patient this behavior is offensive.

C. Report it to your supervisor.

D. Document it. lol (with PICTURE???)

Anyway I fussed around and changed between A & B, and finally settled on B, because I recalled something about limit setting. A is probably correct, and I know the client is sick, etc., however a physical violation like that should not go unreprimanded. Is this truly like "the client is always right?" kind of thing. I know it would be very difficult for me to think clearly enough to ask and analyze the patient's answer. I may do that AFTER telling him it was an offensive overture. Should we question and give the client the opportunity to justify all actions? I mean the whole goal is to prepare the patient for re-entry into the real world, and I think it is a normal reaction to set limits with this type of action, or it may be done again. Maybe someone with experience could explain "limit setting" to me.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

I don't know what the "right" answer is. I would first find out what the meaning is. It could be totally innocent.......then tell him/her it's inappropriate, innocent or not. Then document it, and perhaps report it to the supervisor.

By finding out the meaning, you can respond with what you think is a more appropriate way to expressive him/herself.

I hate these kinds of questions, where all are essentially correct.

Specializes in Geriatrics/Oncology/Psych/College Health.

So which one wound up being the "right" answer?

Specializes in Utilization Management.

All I know is if patient, male or female, did that to me, manic episode or not, I would consider it extremely inappropriate behavior and I would have to say so.

It's probably the wrong answer, but my gut reaction would be to feel creeped out.

Hi. I haven't spoken with our professor yet, but will let you know when I do. Some of my friends responded the same as I did.

Specializes in Med-surg.

Well... all I know is when I'm manic, my caregivers are really careful to set limits. And I'm in love with everyone. lol. I think B is the best answer.

Specializes in Geriatrics/Oncology/Psych/College Health.

The only thing I didn't like about B was use of the word "offensive" but that's more a stylistic thing - I would say "inappropriate."

The only thing I didn't like about B was use of the word "offensive" but that's more a stylistic thing - I would say "inappropriate."

I would say D. Hypersexuality is an acute manifestation of mania. Such actions indicate drugs may not be working and MD needs to consder changing/increasing them.

None of those answers were bad, but what he did was clinically significant and the MD needs to know.

Without wavering I believe the answer is "B".

The nurse's first reaction should be to address the behavior. Which answer meets this the best?

A. Whatever the meaning of the patient's action it is not appropriate. Don't go there.

B. "Offensive" may not be the adjective you would have chosen but this answer addresses the behavior.

C. This can be done later.

D. This can be done later.

Today we had the final exam in Mental Health. One of the questions that is bothering me until now concerns:

what a nurse's first reaction should be when a client who is having a manic episode comes up to the nurse, hugs and kisses her on the mouth. She is totally taken by surprise.

The options were something like this:

A. Ask the patient what the meaning of this action is.

B. Tell the patient this behavior is offensive.

C. Report it to your supervisor.

D. Document it. lol (with PICTURE???)

Anyway I fussed around and changed between A & B, and finally settled on B, because I recalled something about limit setting. A is probably correct, and I know the client is sick, etc., however a physical violation like that should not go unreprimanded. Is this truly like "the client is always right?" kind of thing. I know it would be very difficult for me to think clearly enough to ask and analyze the patient's answer. I may do that AFTER telling him it was an offensive overture. Should we question and give the client the opportunity to justify all actions? I mean the whole goal is to prepare the patient for re-entry into the real world, and I think it is a normal reaction to set limits with this type of action, or it may be done again. Maybe someone with experience could explain "limit setting" to me.

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