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

Answer and Explanation

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 B

Explanation

A. fluoxetine (Prozac):

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. While SSRIs can have side effects, significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance are not typically associated with fluoxetine. The primary concerns with SSRIs are related to serotonin levels and can include gastrointestinal disturbances, insomnia, and sexual dysfunction.

B. Lithium (Lithobid):

This is the correct answer. Lithium is known to have potential side effects related to cardiac and cerebral function, as well as fluid and electrolyte balance. Monitoring blood levels of lithium is crucial to avoid toxicity, which can affect the cardiovascular and central nervous systems. Lithium toxicity can lead to symptoms such as tremors, confusion, ataxia, and, in severe cases, seizures.

C. venlafaxine (Effexor):

Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) commonly used to treat depression and anxiety disorders. While it can cause some cardiovascular effects, the concern for significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance is generally lower compared to lithium. The primary side effects of venlafaxine are related to serotonin and norepinephrine levels and may include increased blood pressure and heart rate.

D. clozapine (Clozaril):

Clozapine is an atypical antipsychotic medication used to treat schizophrenia. While antipsychotics can have side effects related to metabolic changes, significant alterations in cardiac or electrolyte imbalances are not typically associated with clozapine as the primary concern. Regular monitoring for metabolic side effects, such as weight gain and changes in lipid and glucose levels, is important with antipsychotic medications.

A. Limit time for the client to perform activities B. Rotate assignment of daily caregivers. C. Provide an activity schedule that changes from day to day. D. Talk the client through tasks one step at a time

Correct Answer is D

Explanation

A. Limit time for the client to perform activities:

This option may increase agitation and frustration for the client with Alzheimer's disease. It is generally not recommended to limit their time for activities, as it may lead to distress.

B. Rotate assignment of daily caregivers:

Consistency in caregivers is often beneficial for individuals with Alzheimer's disease. Constantly changing caregivers can lead to confusion and anxiety for the client. Thus, rotating caregivers is not the best approach.

C. Provide an activity schedule that changes from day to day:

Individuals with Alzheimer's disease often benefit from routine and predictability. Changing the activity schedule daily can cause confusion and disorientation. Therefore, it is not the most appropriate intervention.

D. Talk the client through tasks one step at a time:

This is the best choice because breaking down tasks into simple, manageable steps can help individuals with Alzheimer's disease understand and follow instructions. It promotes a sense of accomplishment and reduces frustration. This approach is aligned with the principles of dementia care.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving:

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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