A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:
is not responding to other clients on the unit.
angrily argues with another client stating, "God is dead."
is refusing to take his prescribed mood stabilizer.
states, "There is no future when you feel so depressed."
The Correct Answer is D
D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. It's essential for the client to receive accurate information about their safety, efficacy, and potential interactions with other medications. Health food store employees may not always have the necessary expertise to provide comprehensive information on these aspects.
A. Yoga can indeed improve flexibility and balance, which can be beneficial for individuals with osteoarthritis. Therefore, this choice does not indicate a need for client teaching.
C. Glucosamine helps with pain control and bone remodeling to improve overall functionality.
D. Prayer and spirituality can provide emotional support and improve overall well-being, they may not directly address the underlying physical symptoms of osteoarthritis. This may indicate a need for client teaching, as it may reflect the client's personal beliefs and coping strategies.
Correct Answer is D
Explanation
D. This recognizes that the client's improvement in mood is a typical response to antidepressant medication and does not automatically suggest any negative outcomes such as suicidal ideation or serotonin syndrome.
A. It's important to be vigilant for signs of suicidal ideation but sudden improvements in mood can also occur as a positive response to antidepressant medication.
B. The client's description of feeling better does not align with the symptoms of serotonin syndrome, which include agitation, confusion, rapid heart rate, high blood pressure, and hyperthermia.
C. Antidepressant medications often take several weeks to reach their full therapeutic effect, so it's not unusual for some clients to experience an improvement in mood within the first few weeks of treatment.
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