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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
Monitoring signs of psychomotor agitation is essential when assessing a patient with bipolar disorder. Psychomotor agitation can occur during manic episodes and is characterized by restlessness, increased activity, and difficulty sitting still. This is a behavioral manifestation closely tied to the patient's psychological state.
Choice B rationale:
Assessing the patient's memory and attention is important in understanding cognitive functioning. Bipolar disorder can have cognitive impacts, and assessing memory and attention can help identify potential deficits or changes in cognitive abilities that might accompany mood fluctuations.
Choice C rationale:
Documenting the patient's medication history is important for the overall care of a patient with bipolar disorder, but it primarily pertains to their medical management rather than the physical assessment aspect. Choices A, B, D, and E are more directly related to the physical and psychosocial assessment of the patient.
Choice D rationale:
Measuring vital signs and laboratory tests can provide valuable information about the patient's physical health, which can be affected by medications or coexisting medical conditions. This is important to ensure the patient's overall well-being and safety.
Choice E rationale:
Observing signs of impaired judgment is crucial in assessing a patient with bipolar disorder. Impaired judgment can be evident during manic episodes and might lead to risky behaviors. This aspect directly relates to the patient's mental state and psychosocial functioning.
Correct Answer is B
Explanation
Choice A rationale:
Coherence, logic, relevance, and organization. Rationale: This choice is related to assessing the thought process, but it does not accurately address the specific signs described in the scenario: flight of ideas, racing thoughts, and tangentiality. These are characteristic features of a manic or hypomanic episode in bipolar disorder and involve a rapid flow of thoughts, lack of focus, and difficulty maintaining a coherent and organized thought process.
Choice B rationale:
Flight of ideas, racing thoughts, and tangentiality. Rationale: This statement is correct. Flight of ideas, racing thoughts, and tangentiality are indicative of disorganized thought processes commonly seen in manic episodes of bipolar disorder. Flight of ideas refers to a rapid succession of thoughts that may be loosely connected. Racing thoughts involve a constant stream of rapid thoughts, often making it difficult for the individual to concentrate. Tangentiality refers to veering off-topic during conversation and difficulty sticking to the main point.
Choice C rationale:
Themes, topics, beliefs, and perceptions. Rationale: While understanding themes, topics, beliefs, and perceptions is important in a comprehensive psychiatric assessment, this choice does not address the specific signs of disorganized thought processes mentioned in the scenario. Themes and beliefs might be explored during a broader assessment, but flight of ideas, racing thoughts, and tangentiality are more indicative of the manic phase in bipolar disorder.
Choice D rationale:
Signs of delusions, hallucinations, paranoia. Rationale: Delusions, hallucinations, and paranoia are important aspects to assess in individuals with bipolar disorder, but they are not directly related to the disorganized thought processes described in the scenario. Delusions are false beliefs, hallucinations involve sensory perceptions without external stimuli, and paranoia is excessive distrust or suspicion. These symptoms are more characteristic of psychotic disorders or severe mood episodes but are not specific to the described thought process.
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