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:

Documenting signs of psychomotor agitation.

Observing the patient's thought content.

Assessing the patient's physical status.

Measuring the patient's weight and height.

Monitoring signs of flat affect.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Documenting signs of psychomotor agitation is crucial when assessing a client with bipolar disorder experiencing a mixed mood state. Psychomotor agitation is a hallmark of mixed states, which are characterized by the simultaneous presence of manic and depressive symptoms. Documenting these signs helps the nurse to monitor the severity of agitation, which can inform the treatment plan and interventions.

Choice B rationale:

Observing the patient's thought content is essential during a mixed mood state assessment. Clients in a mixed mood state may experience racing thoughts, flight of ideas, or rapid speech, which are indicative of the manic component. Conversely, they may also have negative and depressive thought content due to the depressive aspect. Assessing thought content helps the nurse understand the client's mental state and make appropriate clinical judgments.

Choice C rationale:

Assessing the patient's physical status is a high-priority assessment aspect. Clients in a mixed mood state can exhibit a range of physical symptoms, including changes in sleep patterns, appetite disturbances, and psychomotor agitation. These physical manifestations are integral to the overall presentation of the mixed mood state and contribute to the formulation of an effective care plan.

Choice D rationale:

Measuring the patient's weight and height is not directly relevant to assessing a client with bipolar disorder experiencing a mixed mood state. While monitoring a patient's weight and height might be important for general health assessments, they are not specific priorities when evaluating the symptoms of a mixed mood state.

Choice E rationale:

Monitoring signs of flat affect is not a primary priority when assessing a client with bipolar disorder experiencing a mixed mood state. Flat affect is more commonly associated with depressive states rather than mixed states. While it's important to consider affect, other symptoms like psychomotor agitation and thought content are more indicative of a mixed mood state.

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Correct Answer is D

Explanation

Choice A rationale:

The patient's thought content and organization. Rationale: While monitoring thought content and organization is important in psychiatric assessment, it is not directly related to observing and documenting the patient's mood state. Thought content and organization involve assessing the coherence, relevance, and logic of the patient's thoughts, which can provide insights into their cognitive functioning and potential psychiatric conditions like schizophrenia.

Choice B rationale:

The patient's physical vital signs and laboratory tests. Rationale: This choice is unrelated to the assessment of the patient's mood state. Vital signs and laboratory tests are essential in medical assessments, but when evaluating a patient with bipolar disorder, the focus should be on their psychological and emotional state rather than physical parameters.

Choice C rationale:

The patient's cognitive abilities, memory, and concentration. Rationale: While cognitive abilities, memory, and concentration are important factors to consider in a comprehensive mental status assessment, they are distinct from the patient's mood state. Cognitive assessment provides information about cognitive impairments that might accompany mood disorders, but it does not directly reflect the patient's current emotional state.

Choice D rationale:

The patient's mood state, such as euphoric, irritable, depressed, or mixed. Rationale: This statement is correct. Assessing and documenting the patient's mood state is crucial when evaluating individuals with bipolar disorder. The mood state can provide valuable information about the phase of the disorder (e.g., manic, hypomanic, depressive) and guide treatment decisions. Mood variations are a hallmark of bipolar disorder, and accurately identifying the patient's mood at the time of assessment is essential for effective care.

A. Orientation, memory, and attention. B. Physical vital signs and laboratory tests. C. Coherence, logic, and continuity of thought. D. Signs of confusion, disorientation, and amnesia.

Correct Answer is A

Explanation

Choice A rationale:

The correct answer is A, "Orientation, memory, and attention." Impaired judgment and poor insight can be indicative of cognitive dysfunction in bipolar disorder. Assessing orientation (awareness of time, place, and person), memory (short-term and long-term memory abilities), and attention (ability to focus and concentrate) can provide insights into cognitive deficits that may be contributing to impaired judgment.

Choice B rationale:

"Physical vital signs and laboratory tests" are essential assessments, but they are not directly related to the cognitive abilities of the client. They focus on physiological aspects rather than cognitive functioning.

Choice C rationale:

"Coherence, logic, and continuity of thought" are aspects of thought processes, not cognitive abilities like memory and attention. These are more relevant to assessing thought disorders or psychosis.

Choice D rationale:

"Signs of confusion, disorientation, and amnesia" are relevant to cognitive assessment, but this choice does not cover the breadth of cognitive abilities encompassed by choice A.

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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:

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Naxlex Comprehensive Predictor Exams

A nurse is conducting an assessment of a patient with bipolar disorder. Which aspect of the patient's mental status should the nurse observe and document in relation to their mood state?

Correct Answer is D

Explanation

A client with bipolar disorder is exhibiting signs of impaired judgment and poor insight. What should the nurse assess and document about the client's cognitive abilities?

Correct Answer is A

Explanation

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