A nurse is assessing a patient with bipolar disorder. The nurse observes signs of psychomotor agitation, racing thoughts, and tangentiality. What should the nurse document about the patient's thought process?
Coherence, logic, relevance, and organization.
Flight of ideas, racing thoughts, and tangentiality.
Themes, topics, beliefs, and perceptions.
Signs of delusions, hallucinations, paranoia.
The Correct Answer is B
Choice A rationale:
Coherence, logic, relevance, and organization. Rationale: This choice is related to assessing the thought process, but it does not accurately address the specific signs described in the scenario: flight of ideas, racing thoughts, and tangentiality. These are characteristic features of a manic or hypomanic episode in bipolar disorder and involve a rapid flow of thoughts, lack of focus, and difficulty maintaining a coherent and organized thought process.
Choice B rationale:
Flight of ideas, racing thoughts, and tangentiality. Rationale: This statement is correct. Flight of ideas, racing thoughts, and tangentiality are indicative of disorganized thought processes commonly seen in manic episodes of bipolar disorder. Flight of ideas refers to a rapid succession of thoughts that may be loosely connected. Racing thoughts involve a constant stream of rapid thoughts, often making it difficult for the individual to concentrate. Tangentiality refers to veering off-topic during conversation and difficulty sticking to the main point.
Choice C rationale:
Themes, topics, beliefs, and perceptions. Rationale: While understanding themes, topics, beliefs, and perceptions is important in a comprehensive psychiatric assessment, this choice does not address the specific signs of disorganized thought processes mentioned in the scenario. Themes and beliefs might be explored during a broader assessment, but flight of ideas, racing thoughts, and tangentiality are more indicative of the manic phase in bipolar disorder.
Choice D rationale:
Signs of delusions, hallucinations, paranoia. Rationale: Delusions, hallucinations, and paranoia are important aspects to assess in individuals with bipolar disorder, but they are not directly related to the disorganized thought processes described in the scenario. Delusions are false beliefs, hallucinations involve sensory perceptions without external stimuli, and paranoia is excessive distrust or suspicion. These symptoms are more characteristic of psychotic disorders or severe mood episodes but are not specific to the described thought process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Evaluating the effectiveness of interventions is the primary goal of the nursing process during the implementation phase for a patient with bipolar disorder. Bipolar disorder is a chronic condition that requires ongoing management, and interventions are implemented to address both manic and depressive symptoms. By evaluating the effectiveness of interventions, the nurse can determine if the patient's symptoms are improving, worsening, or remaining stable. This information guides further adjustments to the care plan, ensuring that the patient receives the most appropriate and beneficial treatment.
Choice A rationale:
Collecting data about the patient's physical status is an important aspect of the assessment phase, not the implementation phase, of the nursing process. While physical status assessment informs the development of the care plan, the primary focus of implementation is to put the planned interventions into action and evaluate their outcomes.
Choice C rationale:
Planning evidence-based interventions for the patient is a crucial step in the planning phase of the nursing process. During this phase, the nurse identifies interventions that are tailored to the patient's specific needs and based on evidence-based practice. Once the planning is complete, the nurse moves on to implementing the interventions and subsequently evaluating their effectiveness.
Choice D rationale:
Administering pharmacological treatments is an action that falls within the implementation phase of the nursing process. However, it is not the primary goal of this phase for a patient with bipolar disorder. While pharmacological treatments may be part of the interventions, the primary focus is on evaluating the outcomes of these interventions to ensure the patient's symptoms are being effectively managed.
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Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: This response is not appropriate as rating a mood as 9 indicates a very high mood, possibly hypomania or mania, rather than stability.
Choice B rationale: This response incorrectly interprets the client's rating. A 9 indicates a high mood, not a low one.
Choice C rationale: Asking the client to explain why they rated their mood so high allows the nurse to gather more information about the client's current state and any possible symptoms of mania.
Choice D rationale: This response is incorrect as a mood rating of 9 indicates a high mood, not depression.
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