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 C
Explanation
Choice A reason:Comparing the male nurse to the male doctor dismisses the client’s trauma-related concerns and may make her feel invalidated. It does not prioritize her comfort or safety, which is critical after a domestic abuse incident.
Choice B reason:Emphasizing the nurse’s capability ignores the client’s expressed discomfort with a male caregiver, which may be linked to her trauma. This response fails to address her emotional needs and safety concerns.
Choice C reason:Offering to reassign a female nurse respects the client’s preference and acknowledges the potential trauma-related sensitivity to male caregivers. This response prioritizes her comfort and trust in the care environment.
Choice D reason:Offering to assist with hygiene is irrelevant to the client’s request for a female nurse and does not address her concern about the gender of her caregiver. It fails to provide a solution to her stated discomfort.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:Tremors, particularly in the hands, are a common symptom of alcohol withdrawal, often appearing within hours of the last drink. They are caused by the nervous system’s hyperexcitability due to the absence of alcohol’s depressant effects, making this a key manifestation to include in teaching.
Choice B reason:Polyphagia, or excessive hunger, is not a typical symptom of alcohol withdrawal. Withdrawal is more commonly associated with loss of appetite or nausea due to gastrointestinal distress and nervous system dysregulation, so this should not be included in the teaching.
Choice C reason:Nystagmus, an involuntary eye movement, can occur in alcohol withdrawal, particularly in severe cases or during delirium tremens. It is a neurological symptom resulting from the brain’s response to withdrawal, making it appropriate to include in the teaching.
Choice D reason:Seizures are a serious and potentially life-threatening complication of alcohol withdrawal, often occurring within 12 to 48 hours after the last drink. Educating the client about this risk is critical, as it underscores the need for medical supervision during withdrawal.
Choice E reason:Illusions, or misinterpretations of sensory stimuli, are common in alcohol withdrawal, especially during severe stages like delirium tremens. These perceptual disturbances should be included in the teaching to prepare the client for possible symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.