A client is admitted with a diagnosis of major depression and states, “Nothing brings me pleasure anymore.” Which behaviors will the nurse assess that correlate with the diagnosis?

Choice A reason: Feelings of grandiosity are more characteristic of mania in bipolar I disorder. Hypomania in bipolar II involves milder elevated mood, energy, and confidence without extreme grandiosity, making this symptom less consistent with a hypomanic episode.

Choice B reason: Total loss of interest in activities is a depressive symptom, not hypomania. Hypomanic episodes involve increased energy and engagement in activities, often with heightened productivity or creativity, making this inconsistent with the client’s current state.

Choice C reason: Decreased need for sleep is a hallmark of hypomania in bipolar II, where clients feel rested after minimal sleep due to heightened energy from altered dopamine and norepinephrine activity. This is highly consistent with hypomanic episodes, distinguishing it from mania.

Choice D reason: Severe depressive moods characterize the depressive phase of bipolar II, not hypomania. Hypomanic episodes involve elevated mood and energy, contrasting with the low mood and fatigue of depression, making this inconsistent.

Choice A reason: Drawing blood for lab studies, such as BNP or electrolytes, is important in heart failure to assess severity and guide treatment. However, 2+ pitting edema and left ventricular enlargement suggest acute pulmonary congestion, making respiratory assessment the priority to detect life-threatening complications like pulmonary edema.

Choice B reason: Weighing the client monitors fluid status in heart failure, as weight gain indicates fluid retention. While important, it is secondary to assessing respiratory status, as edema and ventricular enlargement suggest possible pulmonary edema, which poses an immediate threat to oxygenation.

Choice C reason: Left ventricular enlargement and 2+ pitting edema indicate left-sided heart failure, which can lead to pulmonary edema, causing dyspnea and hypoxia. Assessing respiratory status first ensures detection of crackles or respiratory distress, enabling prompt intervention to prevent respiratory failure or worsening heart failure.

Choice D reason: Inserting a Foley catheter monitors urine output in heart failure but is not the first action. Respiratory distress from pulmonary edema, suggested by edema and ventricular enlargement, is a more immediate concern, requiring assessment of breathing to ensure adequate oxygenation and safety.