A male client with bipolar disorder reports to the practical nurse (PN) that he has not taken his prescribed medication, divalproex sodium, for the last 6 months. Assessment of which parameter is most important for the PN to obtain?
Frame of mind.
Speech pattern.
Hyperactivity.
Headache pain.
The Correct Answer is A
A. Frame of mind: Assessing the client’s current mental and emotional state is the top priority because discontinuation of divalproex sodium can lead to recurrence of manic or depressive episodes. Evaluating mood stability, presence of suicidal or manic thoughts, and overall mental status helps determine immediate safety needs and guides further intervention.
B. Speech pattern: While pressured or rapid speech may indicate mania, it is a secondary observation that supports mood assessment rather than the initial focus. The PN must first establish the client’s overall psychological state before analyzing communication details.
C. Hyperactivity: Increased activity and restlessness can occur in mania, but this symptom should be assessed in the broader context of the client’s mood and thought processes, making it less urgent than assessing overall frame of mind.
D. Headache pain: Headache is not typically associated with medication discontinuation in bipolar disorder. Although physical discomfort should be noted, it does not provide critical information about the client’s psychiatric stability or immediate risk level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Expressing anger with his roommate: While the client’s frustration should be addressed to maintain comfort and therapeutic rapport, anger does not pose an immediate physical risk. This concern can safely be managed after attending to clients with higher safety priorities.
B. Complaining of dried blood on gown: Dried blood may suggest mild oozing at a previous procedure site, but it is not an immediate emergency. The client should be assessed soon, but not before evaluating someone at risk of injury or active harm.
C. Attempting to get out of bed: A client with a history of falls attempting to ambulate unassisted faces immediate danger of physical injury. Fall prevention takes priority because it represents an urgent safety issue that can lead to fractures, head trauma, or internal bleeding if not promptly addressed.
D. Requesting pain medication: Pain management is important for client comfort and recovery, but it is a lower priority compared to preventing imminent physical harm. Once safety is ensured, pain control can be addressed appropriately.
Correct Answer is C
Explanation
A. Confirm accuracy of the pulse rate obtained by the UAP: Verifying the rate ensures accuracy but does not address an error in technique. If the UAP is using an incorrect location or method, the pulse reading may be unreliable even if counted correctly.
B. Instruct the UAP to report any abnormal findings: While reporting abnormal findings is an essential part of delegation, this instruction assumes the UAP is performing the skill correctly. The nurse must first ensure that the UAP understands proper technique before emphasizing reporting.
C. Demonstrate the correct pulse site to the UAP: The practical nurse should demonstrate the correct placement of fingers over the radial artery to ensure accurate assessment. Teaching proper technique prevents future errors, promotes competency, and upholds patient safety.
D. Remind the UAP to check the client's pulse volume: Assessing pulse volume is an important observation, but if the pulse site is incorrect, the measurement will not be valid. Correct technique must be established before refining assessment details such as volume.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.