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","C","D"]

Explanation

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

A. 15 ml B. 20 mi C. 25 ml D. 10 ml

Correct Answer is A

Explanation

A. Correct. Using the proportion, the correct dose of fluoxetine (Prozac) for the prescribed 60 mg is 15 mL.

B. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 20 mL.

C. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 25 mL.

D. Incorrect. This is not the correct dose. The correct dose is 15 mL, not 10 mL.

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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

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

A client diagnosed with bulimia nervosa is to receive fluoxetine (Prozac) by oral solution. The medication is supplied in a 100-ml bottle. The label reads 20 mg/5mL.. The doctor orders 60 mg q day. Which dose of this medication should the nurse dispense?

Correct Answer is A

Explanation

Which hallucination necessitates the nurse to implement safety measures? The patient says.

A nurse instructs a patient taking a drug that inhibits monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

Why are behavior modification programs the treatment of choice for clients diagnosed with eating disorders?

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A patient diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other Infected people. Which problem is evident?

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

A 19 year old patient has a diagnosis of Borderline personality disorder. The patient approaches the nurse and shows multiple fresh cuts on both arms. Which is the most therapeutic response by the nurse?