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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Methylphenidate is a central nervous system stimulant commonly used in the treatment of ADHD. It works by increasing the levels of certain neurotransmitters in the brain, which helps improve attention, focus, and impulse control in individuals with ADHD. Teaching the family about methylphenidate would be appropriate as it is one of the most commonly prescribed medications for ADHD.
A. Fluphenazine is an antipsychotic medication primarily used to treat psychotic disorders such as schizophrenia and bipolar disorder. It is not typically used as a first-line treatment for ADHD
C. Diazepam is a benzodiazepine medication primarily used to treat anxiety disorders, muscle spasms, and seizures. It is not indicated for the treatment of ADHD.
D. Haloperidol is an antipsychotic medication primarily used to treat psychotic disorders and severe behavioral disturbances. It is not a first-line treatment for ADHD.
Correct Answer is D
Explanation
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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