A client in a manic episode is having difficulty concentrating and frequently changes topics during conversation. Which nursing response is appropriate in this situation?
"You're not making any sense right now. Can you focus?”
"I'm here to listen. Let's try to stick to one topic at a time.”
"Please stop interrupting and let others speak as well.”
"I don't understand what you're trying to say.”
The Correct Answer is B
Choice A rationale:
This response is not appropriate as it may come across as confrontational and dismissive of the client's current state. The client's difficulty in concentrating is a symptom of their manic episode, and using such phrasing might increase their agitation and escalate the situation.
Choice B rationale:
"I'm here to listen. Let's try to stick to one topic at a time." This response acknowledges the client's difficulty while providing support and a gentle redirection to stay focused on one topic. It maintains a therapeutic and non-confrontational approach, promoting effective communication with the client.
Choice C rationale:
While it's important to ensure fair participation in group conversations, this response may not address the immediate need of the client in a manic episode. It could potentially trigger further irritability or resistance from the client.
Choice D rationale:
This response may be interpreted as the nurse not making an effort to understand the client's thoughts, which could exacerbate the client's frustration and hinder therapeutic communication. It lacks empathy and a collaborative approach.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A rationale:
This statement is not accurate for a depressive episode. Excessive involvement in risky activities is more characteristic of a manic episode in bipolar disorder, not a depressive one. Manic episodes are marked by increased energy levels and impulsivity.
Choice B rationale:
An increase in goal-directed activity is not a typical symptom of a depressive episode. Depressive episodes are associated with a decrease in energy, motivation, and interest in previously enjoyed activities, leading to reduced activity levels.
Choice C rationale:
A decreased need for sleep is more commonly associated with manic episodes, where individuals experience a reduced need for sleep due to heightened energy levels. In depressive episodes, sleep disturbances such as insomnia are more prevalent.
Choice D rationale:
Significant weight loss or gain without intentional effort is a possible symptom. Changes in appetite and weight are hallmark features of a depressive episode. Clients may experience a loss of interest in food and subsequently lose weight, or they might engage in "comfort eating," leading to weight gain.
Correct Answer is D
Explanation
Choice A rationale: Collecting data about the patient's physical status is the "Assessment" phase of the nursing process. This step involves gathering baseline information to identify the patient's needs and problems before any interventions are developed or performed.
Choice B rationale: Evaluating the effectiveness of the interventions is the "Evaluation" phase. In this final step, the nurse compares the patient's current status against the expected outcomes to determine if the plan of care was successful.
Choice C rationale: Planning evidence-based interventions for the patient is the "Planning" phase. During this stage, the nurse sets measurable goals and selects specific nursing actions designed to achieve those goals based on the earlier assessment data.
Choice D rationale: Administering pharmacological treatments occurs during the "Implementation" phase. This phase involves the actual execution of the nursing care plan, including performing ordered treatments, providing education, and managing medications to stabilize the patient's bipolar symptoms.
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