A client has been admitted to a psychiatric mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has been displaying manic symptoms for the past 2 weeks. The spouse reports that the client has not slept for the past 2 days, and that the client has not eaten anything for at least 3 days.
Which would be the priority nursing diagnosis for this client?
Ineffective health maintenance
Risk for other-directed violence
Risk for imbalanced nutrition
Risk for suicide
The Correct Answer is C
A) Incorrect. While the client's sleep disturbance and lack of selfcare may contribute to
ineffective health maintenance, the more immediate concern is addressing the risk of imbalanced nutrition.
B) Incorrect. While clients in a manic state may exhibit hyperactivity and impulsivity, there is no indication in the scenario that the client poses an immediate risk for other-directed violence.
C) Correct. The client's reported lack of sleep and refusal to eat for an extended period raises concerns about nutritional deficits and dehydration. This is the most immediate and pressing issue to address.
D) Incorrect. While the client's manic state may increase the risk of impulsive behavior, there is no specific indication in the scenario that the client is at immediate risk for suicide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increase your fluid and fiber intake to prevent constipation – Risperidone, an atypical antipsychotic, can cause constipation due to its anticholinergic effects. Increasing fluid and fiber intake can help prevent this.
B. Have your blood pressure checked frequently for hypertension – Risperidone is more commonly associated with orthostatic hypotension, not hypertension.
C. Expect to have your blood checked weekly for serum electrolyte imbalances – Unlike clozapine, risperidone does not require frequent blood monitoring for electrolyte imbalances.
D. Increase caloric intake to prevent weight loss – Risperidone is more likely to cause weight gain rather than weight loss, so increasing caloric intake is unnecessary.
Correct Answer is ["A","D","F"]
Explanation
A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.
B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.
C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.
D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.
E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.
F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.
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