A nurse is assessing a client who is exhibiting symptoms of a manic episode. The client states, "I am the most important person in the world, and I have unique abilities that no one else possesses." What is the appropriate nursing response?

"It sounds like you're feeling pretty good about yourself.".

"I'm sorry you're feeling this way. Would you like to talk more?".

"You're mistaken. Nobody has special talents like that.".

"It seems like you're having trouble understanding reality.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Correct Choice Responding with empathy and reflecting the client's feelings is important in therapeutic communication. In this scenario, the client is exhibiting grandiose beliefs and a heightened sense of self-importance. The response acknowledges the client's feelings without necessarily agreeing or disagreeing, maintaining a nonjudgmental stance.

Choice B rationale:

While offering to listen and talk more is a good approach, the phrasing of this option, "I'm sorry you're feeling this way," could be perceived as dismissive or patronizing. It's important to provide a more empathetic and open response to the client's feelings.

Choice C rationale:

Responding with a contradictory statement might escalate the situation and potentially lead to a power struggle with the client. Challenging the client's beliefs directly could be counterproductive to building a therapeutic relationship.

Choice D rationale:

This response could be interpreted as confrontational and potentially distressing to the client. It's important to maintain a supportive and nonjudgmental stance when communicating with individuals experiencing manic or hypomanic episodes.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale:

Monitoring signs of psychomotor agitation is essential when assessing a patient with bipolar disorder. Psychomotor agitation can occur during manic episodes and is characterized by restlessness, increased activity, and difficulty sitting still. This is a behavioral manifestation closely tied to the patient's psychological state.

Choice B rationale:

Assessing the patient's memory and attention is important in understanding cognitive functioning. Bipolar disorder can have cognitive impacts, and assessing memory and attention can help identify potential deficits or changes in cognitive abilities that might accompany mood fluctuations.

Choice C rationale:

Documenting the patient's medication history is important for the overall care of a patient with bipolar disorder, but it primarily pertains to their medical management rather than the physical assessment aspect. Choices A, B, D, and E are more directly related to the physical and psychosocial assessment of the patient.

Choice D rationale:

Measuring vital signs and laboratory tests can provide valuable information about the patient's physical health, which can be affected by medications or coexisting medical conditions. This is important to ensure the patient's overall well-being and safety.

Choice E rationale:

Observing signs of impaired judgment is crucial in assessing a patient with bipolar disorder. Impaired judgment can be evident during manic episodes and might lead to risky behaviors. This aspect directly relates to the patient's mental state and psychosocial functioning.

A. GAD-7. B. BAI. C. PHQ-9. D. CAGE.

Correct Answer is C

Explanation

Choice A rationale:

The GAD-7 (Generalized Anxiety Disorder 7-item scale) is a self-report questionnaire designed to assess the severity of generalized anxiety symptoms. While anxiety and depression often coexist, the GAD-7 focuses on anxiety symptoms and wouldn't provide a comprehensive assessment of depression severity.

Choice B rationale:

The BAI (Beck Anxiety Inventory) is used to measure the severity of anxiety symptoms, not depression. It wouldn't be the appropriate tool for assessing depression in this context.

Choice C rationale:

This is the correct answer. The PHQ-9 (Patient Health naire-9) is a widely used self-report tool specifically designed to measure the severity of depressive symptoms. It covers various domains of depression, such as mood, sleep, appetite, and concentration, and is suitable for assessing the impact of depression on an individual's functioning.

Choice D rationale:

The CAGE questionnaire is used to assess alcohol misuse, not depression. It consists of four questions aimed at identifying potential alcohol-related problems. While substance use disorders can co-occur with depression, the CAGE is not the appropriate tool for assessing depression severity and impact.

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A nurse is assessing a client who is exhibiting symptoms of a manic episode. The client states, "I am the most important person in the world, and I have unique abilities that no one else possesses." What is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient with bipolar disorder. Which of the following aspects of the assessment should the nurse consider as part of the physical assessment? Select all that apply:

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is assessing a patient with major depressive disorder (MDD). Which assessment tool can the nurse use to measure the severity and impact of depression on the patient’s functioning?

Correct Answer is C

Explanation

A client with bipolar disorder is exhibiting signs of impaired judgment and poor insight. What should the nurse assess and document about the client's cognitive abilities?

(Select all that apply): A nurse is providing care to a patient with MDD. Which of the following are components of nursing assessment for suicide risk in patients with MDD? (Select three).

A client with bipolar disorder is experiencing a mixed mood state. What aspects of the assessment should the nurse prioritize in this situation? Select all that apply:

A nurse is providing education to a patient with MDD who has been prescribed an atypical antidepressant. What should the nurse emphasize as a key aspect of medication adherence?

A nurse is providing education to a group of nursing students about the signs and symptoms of manic episodes in bipolar disorder. Which of the following statements accurately describes a characteristic of a manic episode?

A client with bipolar disorder is prescribed a medication to reduce psychotic symptoms during manic episodes. Which class of medications is commonly used for this purpose?

(Select all that apply): A client with MDD is prescribed an atypical antidepressant. Which statements are true about atypical antidepressants? (Select three).

A nurse is educating a group of nursing students about psychotherapeutic interventions for bipolar disorder. Select all the psychotherapeutic interventions that are commonly used for managing bipolar disorder.