A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
Knowledge deficit R/T bipolar disorder AEB concern about symptoms
Risk for suicide R/T powerlessness AEB insomnia and anorexia
The Correct Answer is A
A. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss: This is the correct priority nursing diagnosis. The client's significant weight loss is indicative of altered nutrition and poses a more immediate threat to their well-being. Addressing the nutritional deficit takes precedence to ensure the client's physical health and stability.
B. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights: While altered sleep patterns are a concern, the priority in this scenario is the significant weight loss, which is indicative of altered nutrition. Nutritional deficits can have more immediate health consequences.
C. Knowledge deficit R/T bipolar disorder AEB concern about symptoms: While addressing knowledge deficits is important for the client's understanding of their condition, the immediate concern is the client's significant weight loss. Nutritional deficits can lead to serious health issues and should be addressed as a priority.
D. Risk for suicide R/T powerlessness AEB insomnia and anorexia: While the client's symptoms may contribute to a risk for suicide, the immediate focus should be on addressing the altered nutrition, which is a more direct threat to the client's physical health.
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Correct Answer is D
Explanation
A. Case Manager:
A case manager is typically responsible for coordinating and managing the overall care and services for a client. This role involves collaboration with various healthcare professionals and services outside the immediate treatment setting.
B. Educator:
An educator is involved in providing information, teaching, and promoting the understanding of health-related topics. While education is an essential component of nursing care, the described actions are more indicative of another role.
C. Counselor:
A counselor focuses on providing emotional support, guidance, and therapeutic communication to help clients explore and address personal issues. While nurses do engage in counseling, the described actions emphasize a broader role.
D. Milieu Manager:
The role of a milieu manager involves organizing and maintaining the therapeutic environment, including scheduling activities, managing interactions, and ensuring safety on a psychiatric unit. This role is crucial for creating a supportive and therapeutic atmosphere for clients.
Correct Answer is A
Explanation
A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.
B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.
C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.
D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.
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