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. "The voices talk only at night when I'm trying to sleep."

This statement does not necessarily indicate a direct threat to the patient or others. It may be a manifestation of hallucination, but it doesn't explicitly pose a danger.

B. "The voices say everyone is trying to kill me."

This statement suggests paranoid delusions and a direct threat to the patient's safety. The nurse should implement safety measures to protect the patient and others from potential harm.

C. "I hear angels playing harps."

This statement describes a positive or benign hallucination, which may not require immediate safety measures. While it might be distressing for the patient, it doesn't pose an imminent danger.

A. Using authoritative leadership to help clients learn to conform to societal norms B. Being firm, consistent, and empathetic, while addressing specific client behaviors C. Promoting client expression by implementing laissez-faire leadership D. Overlooking inappropriate behaviors to avoid promoting secondary gains

Correct Answer is B

Explanation

A. Using authoritative leadership to help clients learn to conform to societal norms: Authoritative leadership may be perceived as controlling and is unlikely to be effective with clients diagnosed with borderline personality disorder. It can lead to resistance and difficulties in building a therapeutic alliance.

B. Being firm, consistent, and empathetic, while addressing specific client behaviors: This approach is most appropriate. Clients with borderline personality disorder often benefit from clear and consistent boundaries, along with empathy from the nurse. Addressing specific behaviors helps establish a structured and safe therapeutic environment.

C. Promoting client expression by implementing laissez-faire leadership: Laissez-faire leadership, characterized by minimal interference or direction, is generally not suitable for clients with borderline personality disorder. They may struggle with emotional dysregulation and benefit from a more structured and supportive approach.

D. Overlooking inappropriate behaviors to avoid promoting secondary gains: Overlooking inappropriate behaviors may reinforce maladaptive patterns and hinder progress in therapy. It is essential to address and work through specific behaviors while maintaining empathy and consistency.

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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

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

Correct Answer is B

Explanation

Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder?

Correct Answer is B

Explanation

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

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