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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

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.

A. "It's great that you're feeling this way. Your mood seems stable.". B. "You must be feeling really low to rate your mood as 9.". C. "Tell me more about why you rated your mood so high.". D. "Your mood rating suggests that you're feeling depressed.".

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.

View Question and Answer

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A client with bipolar disorder rates their mood as 9 on a scale of 1 to 10, where 1 is the lowest and 10 is the highest. What could the nurse say to the client in this situation?

Correct Answer is C

Explanation

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