A client with bipolar disorder is displaying aggressive behavior and impulsivity. What aspect of the patient's behavior should the nurse observe and document during the assessment?
Cognitive abilities, memory, and attention.
The patient's mood state and affect.
The patient's physical height and weight.
Activity level, speech pattern, and self-care.
The Correct Answer is D
Choice A rationale:
Cognitive abilities, memory, and attention are important cognitive functions to assess in patients with bipolar disorder. However, when addressing aggressive behavior and impulsivity, the focus should be on observing and documenting behavioral aspects rather than cognitive functions. These cognitive functions might be affected, but they are not the primary aspects of interest in this context.
Choice B rationale:
The patient's mood state and affect are indeed important considerations, especially in the context of bipolar disorder. However, the question specifically asks about aggressive behavior and impulsivity. While mood and affect might influence behavior, they are not the same as behavior. Choice D directly addresses the aspects of behavior relevant to the situation.
Choice C rationale:
Physical height and weight are not directly relevant to the assessment of aggressive behavior and impulsivity in a client with bipolar disorder. These measurements are more related to physical health rather than the behavioral or psychosocial aspects of the patient's presentation.
Choice D rationale:
This is the correct choice. Aggressive behavior and impulsivity are behavioral manifestations that can provide important insights into the patient's mental state and psychosocial functioning. Observing and documenting activity level, speech pattern, and self-care behaviors can help understand the extent and nature of these behaviors, which are relevant to the client's bipolar disorder diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
Correct Choice Responding with empathy and reflecting the client's feelings is important in therapeutic communication. In this scenario, the client is exhibiting grandiose beliefs and a heightened sense of self-importance. The response acknowledges the client's feelings without necessarily agreeing or disagreeing, maintaining a nonjudgmental stance.
Choice B rationale:
While offering to listen and talk more is a good approach, the phrasing of this option, "I'm sorry you're feeling this way," could be perceived as dismissive or patronizing. It's important to provide a more empathetic and open response to the client's feelings.
Choice C rationale:
Responding with a contradictory statement might escalate the situation and potentially lead to a power struggle with the client. Challenging the client's beliefs directly could be counterproductive to building a therapeutic relationship.
Choice D rationale:
This response could be interpreted as confrontational and potentially distressing to the client. It's important to maintain a supportive and nonjudgmental stance when communicating with individuals experiencing manic or hypomanic episodes.
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