A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

A client diagnosed I with hypomania who is speaking loudly on the unit.

A client diagnosed with hypomania who is complaining of pain.

A client with a history of mania who is pacing in the hallway

A client diagnosed with mania who expressed active suicidal ideations

Answer and Explanation

The Correct Answer is D

A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

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Correct Answer is A

Explanation

A. "I'm the world's most perceptive attorney.": This statement reflects grandiosity, a common feature of grandiose delusions. The client is expressing an exaggerated belief in their own importance and abilities, indicating a distorted perception of reality.

B. "The FBI is out to get me": This statement suggests paranoid delusions, where the client believes they are being persecuted or conspired against. It does not specifically indicate grandiose delusions.

C. "I can't stop my sexual urges. They have led me to numerous affairs": This statement reflects impulsivity and hypersexuality, which are common features in manic episodes but do not specifically indicate grandiose delusions.

D. "My wife is distraught about my overspending": This statement reflects a consequence of manic behavior (overspending) but does not directly indicate grandiose delusions.

A. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment) B. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors C. Because biological tactors are the sole cause of depression, medications will improve your mood D. Environmental factors have been shown to exert the most influence in the development of depression

Correct Answer is B

Explanation

A. Researchers have been unable to demonstrate a link between nature (biology and genetics) and nurture (environment): This statement is inaccurate. There is substantial evidence supporting the interaction between nature (biology and genetics) and nurture (environment) in the development of mental health conditions, including depression.

B. Medications are one way to address chemical imbalances. Environmental and interpersonal factors can also have an impact on biological factors: This is the correct answer. It acknowledges the role of medications in addressing chemical imbalances but also emphasizes the importance of environmental and interpersonal factors in influencing biological factors. This response aligns with a biopsychosocial model of understanding mental health.

C. Because biological factors are the sole cause of depression, medications will improve your mood: This statement oversimplifies the complex etiology of depression. Depression is a multifactorial condition influenced by biological, psychological, and environmental factors. Medications may be part of the treatment, but they are not the sole solution.

D. Environmental factors have been shown to exert the most influence in the development of depression: This statement is also incorrect. Depression is influenced by a combination of biological, psychological, and environmental factors. No single factor is solely responsible for the development of depression.

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A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

Correct Answer is A

Explanation

depressed client states. I have a chemical imbalance in my brain. I have no control over my behavior. Medications are my only hope to feel normal again. Which nursing response is appropriate?

Correct Answer is B

Explanation

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