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 A
Explanation
Choice A rationale:
The correct answer is A, "Orientation, memory, and attention." Impaired judgment and poor insight can be indicative of cognitive dysfunction in bipolar disorder. Assessing orientation (awareness of time, place, and person), memory (short-term and long-term memory abilities), and attention (ability to focus and concentrate) can provide insights into cognitive deficits that may be contributing to impaired judgment.
Choice B rationale:
"Physical vital signs and laboratory tests" are essential assessments, but they are not directly related to the cognitive abilities of the client. They focus on physiological aspects rather than cognitive functioning.
Choice C rationale:
"Coherence, logic, and continuity of thought" are aspects of thought processes, not cognitive abilities like memory and attention. These are more relevant to assessing thought disorders or psychosis.
Choice D rationale:
"Signs of confusion, disorientation, and amnesia" are relevant to cognitive assessment, but this choice does not cover the breadth of cognitive abilities encompassed by choice A.
Correct Answer is D
Explanation
Choice A rationale:
Antidepressants are not commonly used to reduce psychotic symptoms during manic episodes in bipolar disorder. Antidepressants are primarily used to manage depressive symptoms and may exacerbate manic symptoms if used alone.
Choice B rationale:
Mood stabilizers are an appropriate class of medications used to manage bipolar disorder. However, they are more focused on preventing mood swings and stabilizing the mood rather than directly reducing psychotic symptoms during manic episodes.
Choice C rationale:
Benzodiazepines are not typically used as a first-line treatment for reducing psychotic symptoms during manic episodes in bipolar disorder. They might have a sedative effect, but they are not the primary choice for managing acute manic symptoms.
Choice D rationale:
Antipsychotics are commonly used to reduce psychotic symptoms during manic episodes in bipolar disorder. They help to alleviate symptoms such as delusions, hallucinations, and disorganized thinking that can occur during manic episodes. Examples of antipsychotics used in this context include risperidone, olanzapine, and aripiprazole. These medications help stabilize the individual and manage the acute symptoms of mania.
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