A nurse is assessing a client who has bipolar disorder. Which of the following assessment questions is most appropriate?

How would you describe your relationship with your family?

Are you currently having any suicidal thoughts?

If you found an unopened letter on the sidewalk, what would you do?

What is your favorite color?

Answer and Explanation

The Correct Answer is B

Choice A reason: While understanding family dynamics is important for long-term management, it does not address immediate safety concerns. It is more relevant during psychosocial assessments or discharge planning.

Choice B reason: Assessing for suicidal ideation is a priority in clients with bipolar disorder due to the high risk of self-harm during depressive or mixed episodes. This question directly addresses safety and guides urgent intervention if needed.

Choice C reason: This question may assess judgment or abstract thinking but is not a priority in acute assessment. It is more appropriate in cognitive or neuropsychological evaluations.

Choice D reason: Asking about favorite color is irrelevant to psychiatric assessment and does not provide useful clinical information.

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Correct Answer is A

Explanation

Choice A reason: Muscle rigidity is a hallmark symptom of serotonin syndrome, often accompanied by hyperreflexia, tremors, and autonomic instability. It requires immediate intervention.

Choice B reason: Constipation is not associated with serotonin syndrome. It may be a side effect of other medications but is not diagnostic.

Choice C reason: Lethargy is nonspecific and may occur in many conditions. Serotonin syndrome typically presents with agitation and hyperactivity rather than sedation.

Choice D reason: Bradycardia is not typical of serotonin syndrome. Tachycardia and hypertension are more common due to autonomic dysregulation.

A. A nurse checks a sleeping client’s blankets for safety. B. A nurse takes the arm of a client to redirect them after they wander into another client’s room. C. A nurse tells a client they have been depressed due to a recent divorce. D. A nurse reminds a client of their medication schedule.

Correct Answer is C

Explanation

Choice A reason: Checking blankets for safety is a routine and appropriate nursing action. It ensures the client’s well-being without breaching boundaries.

Choice B reason: Redirecting a client with gentle physical guidance is acceptable when done respectfully and for safety purposes. It does not constitute a boundary violation.

Choice C reason: Sharing personal emotional experiences with a client crosses professional boundaries. It shifts focus from the client’s needs and may blur therapeutic roles.

Choice D reason: Reminding a client about medication is part of routine care and does not involve personal disclosure or inappropriate behavior.

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A nurse is assessing a client who has bipolar disorder. Which of the following assessment questions is most appropriate?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

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