A 30-year-old male patient, John, presents to the clinic with his wife. She reports that John has been experiencing periods of extreme energy and euphoria, followed by episodes of deep depression over the past several months. During his manic episodes, John engages in risky behaviors such as excessive spending and reckless driving. During his depressive episodes, he isolates himself and has expressed feelings of hopelessness. Based on this scenario, what is the priority nursing action for John?
Administer a mood stabilizer immediately.
Conduct a thorough assessment to evaluate John's safety and risk of harm to himself or others.
Schedule John for regular therapy sessions to manage his mood swings.
Educate John and his wife about the signs and symptoms of Bipolar Spectrum Disorder.
The Correct Answer is B
Choice A reason: While mood stabilizers are essential in treatment, medication cannot be safely administered before completing an assessment of risk and safety.
Choice B reason: The priority in this scenario is to assess safety, as John is at risk of harming himself or others due to reckless behavior during mania and suicidal ideation during depression. Safety always precedes treatment or education.
Choice C reason: Therapy is a valuable part of long-term management, but it is not the immediate priority when safety concerns exist.
Choice D reason: Education is important but cannot come before determining immediate risk and ensuring safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:Alcohol tolerance is not a medical emergency and is not caused by withdrawal. It refers to needing more alcohol to achieve the same effect, making this statement incorrect.
Choice B reason:Alcohol tolerance involves a decreased physical response to the same amount of alcohol over time, requiring higher doses for the same effect. This statement accurately reflects understanding of tolerance.
Choice C reason:Alcohol tolerance does not produce physical changes when alcohol is not consumed. It describes the body’s reduced response to alcohol, not withdrawal symptoms or other changes.
Choice D reason:Alcohol tolerance does not directly increase the effects of opiates. While cross-tolerance can occur, this statement inaccurately suggests a direct causal relationship, making it incorrect.
Correct Answer is B
Explanation
Choice A reason:Automatic obedience involves unthinkingly following instructions, often seen in catatonia. The client’s oppositional behavior is the opposite, making this an incorrect choice.
Choice B reason:Active negativism, common in schizophrenia, involves deliberately doing the opposite of what is requested, reflecting resistance or opposition. The client’s behavior matches this description.
Choice C reason:Impaired impulse control involves acting on urges without restraint, such as aggression or impulsivity. The client’s deliberate opposition is not impulsive but purposeful, so this is incorrect.
Choice D reason:Waxy flexibility involves maintaining imposed postures, typically in catatonia. The client’s oppositional behavior does not involve physical posturing, making this incorrect.
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