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) Correct. Ecstasy, also known as MDMA (3,4methylenedioxymethamphetamine), belongs to the hallucinogen class of drugs. It produces altered perceptions and sensations.
B) Incorrect. Hypnotics are drugs that promote sleep.
C) Incorrect. Opioids are a class of drugs that include substances like heroin and prescription pain medications.
D) Incorrect. Sedatives are drugs that calm or soothe and can also induce sleep.
Correct Answer is C
Explanation
A) Incorrect. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.
B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.
C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.
D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.
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