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 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.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Dialectical behavior therapy (DBT) is not commonly used as a psychotherapeutic intervention for managing bipolar disorder. DBT is often used to treat borderline personality disorder and focuses on emotional regulation and interpersonal skills.
Choice B rationale:
Cognitive-behavioral therapy (CBT) is commonly used as a psychotherapeutic intervention for managing bipolar disorder. It helps individuals identify and change negative thought patterns and behaviors, which can be valuable in managing both depressive and manic symptoms.
Choice C rationale:
Family-focused therapy (FFT) is commonly used as a psychotherapeutic intervention for managing bipolar disorder. It involves the family in the treatment process and aims to improve communication, problem-solving, and support within the family unit.
Choice D rationale:
Interpersonal and social rhythm therapy (IPSRT) is commonly used as a psychotherapeutic intervention for managing bipolar disorder. It focuses on stabilizing daily routines and sleep patterns, which can help prevent mood episodes and maintain stability.
Choice E rationale:
Exposure therapy is not commonly used for managing bipolar disorder. Exposure therapy is typically used to treat anxiety disorders, particularly phobias and post-traumatic stress disorder (PTSD), and involves gradually exposing individuals to their feared situations or memories to reduce anxiety.
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