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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Incorrect. Allowing the client to continue at his own pace may not effectively address the issue of circumstantiality and could lead to prolonged, tangential conversations.

B) Correct. Redirecting the conversation can help the client refocus and stay on topic, which can be particularly helpful for someone experiencing circumstantiality.

C) Incorrect. Stopping the client and telling him how his conversation sounds to others may be perceived as confrontational and could potentially be distressing for the client.

D) Incorrect. Reflecting is a useful communication technique, but it may not be the most effective intervention for addressing circumstantiality in this scenario.

A. Anhedonia B. Aphasia C. Akathisia D. Agnosia

Correct Answer is D

Explanation

A. Anhedonia is a symptom commonly associated with depression, characterized by a decreased ability to experience pleasure or interest in activities.

B. Aphasia is a language disorder that affects the ability to communicate. It may involve difficulty in speaking, understanding language, reading, or writing. This is not demonstrated in the scenario.

C. Akathisia is a side effect of some antipsychotic medications characterized by a feeling of inner restlessness and the need to move constantly. It is not demonstrated in the scenario.

D. Agnosia is a symptom of dementia characterized by the inability to recognize familiar objects, people, or places, despite the senses being intact. In this scenario, the client's inability to recognize that their glasses are not a form of identification indicates agnosia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives report on a male client diagnosed with schizoaffective disorder and is informed that the client's verbal communication includes "circumstantiality." What intervention is most therapeutic when caring for this client?

Correct Answer is B

Explanation

During the admission process, an elderly client is asked to present their license for identification purposes. The client gives the admission personnel their glasses. This is an example of which of the following symptoms of dementia?

Correct Answer is D

Explanation

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

Which nursing documentation entry accurately describes a client's use of confabulation?

What intervention is a priority when the client is experiencing auditory hallucinations?

The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?

The nurse is admitting a client with the diagnosis of schizophreniform disorder. What should the nurse expect to find?

A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

A nurse is providing teaching for a client who has schizophrenia and a new prescription for risperidone. Which of the following statements should the nurse include in the teaching?

The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?