A client with bipolar disorder is experiencing a mixed mood state. What aspects of the assessment should the nurse prioritize in this situation? Select all that apply:

Choice B rationale:

Evaluating the effectiveness of interventions is the primary goal of the nursing process during the implementation phase for a patient with bipolar disorder. Bipolar disorder is a chronic condition that requires ongoing management, and interventions are implemented to address both manic and depressive symptoms. By evaluating the effectiveness of interventions, the nurse can determine if the patient's symptoms are improving, worsening, or remaining stable. This information guides further adjustments to the care plan, ensuring that the patient receives the most appropriate and beneficial treatment.

Choice A rationale:

Collecting data about the patient's physical status is an important aspect of the assessment phase, not the implementation phase, of the nursing process. While physical status assessment informs the development of the care plan, the primary focus of implementation is to put the planned interventions into action and evaluate their outcomes.

Choice C rationale:

Planning evidence-based interventions for the patient is a crucial step in the planning phase of the nursing process. During this phase, the nurse identifies interventions that are tailored to the patient's specific needs and based on evidence-based practice. Once the planning is complete, the nurse moves on to implementing the interventions and subsequently evaluating their effectiveness.

Choice D rationale:

Administering pharmacological treatments is an action that falls within the implementation phase of the nursing process. However, it is not the primary goal of this phase for a patient with bipolar disorder. While pharmacological treatments may be part of the interventions, the primary focus is on evaluating the outcomes of these interventions to ensure the patient's symptoms are being effectively managed.

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Choice A rationale:

The GAD-7 (Generalized Anxiety Disorder 7-item scale) is a self-report questionnaire designed to assess the severity of generalized anxiety symptoms. While anxiety and depression often coexist, the GAD-7 focuses on anxiety symptoms and wouldn't provide a comprehensive assessment of depression severity.

Choice B rationale:

The BAI (Beck Anxiety Inventory) is used to measure the severity of anxiety symptoms, not depression. It wouldn't be the appropriate tool for assessing depression in this context.

Choice C rationale:

This is the correct answer. The PHQ-9 (Patient Health naire-9) is a widely used self-report tool specifically designed to measure the severity of depressive symptoms. It covers various domains of depression, such as mood, sleep, appetite, and concentration, and is suitable for assessing the impact of depression on an individual's functioning.

Choice D rationale:

The CAGE questionnaire is used to assess alcohol misuse, not depression. It consists of four questions aimed at identifying potential alcohol-related problems. While substance use disorders can co-occur with depression, the CAGE is not the appropriate tool for assessing depression severity and impact.