A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?

Altered thought process related to hallucinations.

Risk for violence related to poor impulse control and judgement.

Altered thought process related to poor judgement.

Social isolation related to mania.

Answer and Explanation

The Correct Answer is B

A. Altered thought process related to hallucinations: While altered thought processes are common in manic episodes, hallucinations are not typically associated with mania in Bipolar I disorder. Hallucinations are more commonly seen in psychotic disorders.

B. Risk for violence related to poor impulse control and judgment: This is the correct priority diagnosis. During a manic episode, individuals may have impaired impulse control and poor judgment, increasing the risk of impulsive and potentially violent behaviors. Ensuring the safety of the client and others is the priority.

C. Altered thought process related to poor judgment: While altered thought processes and poor judgment are characteristic of mania, the specific concern in this scenario is the potential for violence. The risk for violence takes precedence as a priority nursing diagnosis.

D. Social isolation related to mania: Social isolation may be a concern, but the immediate priority is addressing the risk for violence, as it poses a more significant threat to the client and others during a manic episode.

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Correct Answer is B

Explanation

A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.

B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.

C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.

D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.

A. less-restrictive alternatives have been tried without success B. the medication will make the work of the staff easier or safer C. the client is willing to accept the medication D. the clients behavior indicates possible danger to self, others or the environment

Correct Answer is D

Explanation

A. Less-restrictive alternatives have been tried without success: While it is important to explore less-restrictive alternatives before resorting to medication, the immediate concern is the client's safety and the safety of others. If the client's behavior poses a significant risk, prompt intervention may be necessary.

B. The medication will make the work of the staff easier or safer: While staff safety is important, the primary consideration for administering a prn dose of Haloperidol is the clinical need based on the client's behavior and potential danger to themselves, others, or the environment.

C. The client is willing to accept the medication: Client willingness to accept medication is relevant for promoting collaboration in treatment, but the urgency in administering a prn dose is often based on the client's behavior and the level of risk they pose.

D. The client's behavior indicates possible danger to self, others, or the environment: This is the most critical factor in determining the need for a prn dose. If a client's behavior poses a significant risk, such as aggression, violence, or extreme agitation, administering a prn dose of medication may be necessary to ensure safety and prevent harm.

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A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia states, Can't you hear him? Its the devil. He's telling me I'm going to hell. Which is the most appropriate nursing reply?

Correct Answer is B

Explanation

For the nurse managing the therapeutic milieu, the most heavily weighted factor in determining whether a client should receive a prn dose of Haloperidol is whether

Correct Answer is D

Explanation

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