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:
Monitoring signs of psychomotor agitation.
Assessing the patient's memory and attention.
Documenting the patient's medication history.
Measuring vital signs and laboratory tests.
Observing signs of impaired judgment.
Correct Answer : A,B,D,E
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.
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Correct Answer is D
Explanation
Choice A rationale:
Antipsychotics are often used to manage acute manic episodes in bipolar disorder, but they are not considered the gold standard for overall treatment. They may have a role as adjunctive therapy or in specific situations, but they are not typically the primary choice for maintenance treatment.
Choice B rationale:
Antidepressants are used in bipolar disorder treatment, but they are often cautiously prescribed due to the risk of triggering manic episodes or rapid cycling. They are not considered the gold standard due to this potential for destabilization.
Choice C rationale:
Benzodiazepines may be used to manage acute agitation or anxiety in bipolar disorder, but they are not the gold standard for long-term treatment. Prolonged use can lead to dependence and may not address the underlying mood instability.
Choice D rationale:
Mood stabilizers. Mood stabilizers like lithium, valproate (divalproex), and lamotrigine are considered the gold standard for bipolar disorder treatment due to their efficacy in managing both acute episodes (manic, hypomanic, and depressive) and providing long-term stabilization. These medications help prevent relapses and mood swings by regulating neurotransmitters and stabilizing mood fluctuations.
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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