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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Histrionic Personality Disorder:
Individuals with histrionic personality disorder typically seek attention and may be overly dramatic, but self-harm as a response to perceived abandonment is not a characteristic feature.
B. Obsessive-Compulsive Personality Disorder (OCPD):
People with obsessive-compulsive personality disorder are characterized by perfectionism, preoccupation with details, and a desire for control. Michelle's behavior, including self-harm in response to perceived rejection, aligns more closely with borderline personality disorder.
C. Narcissistic Personality Disorder:
While narcissistic individuals may exhibit a sense of superiority and a desire for admiration, self-harm in response to abandonment is not a typical trait of narcissistic personality disorder.
D. Borderline Personality Disorder (BPD):
This personality disorder is characterized by unstable relationships, self-image, and emotions. Individuals with BPD may have intense fears of abandonment and engage in impulsive and self-destructive behaviors. Michelle's perception of being disliked, her claim of superiority, and the self-harming action in response to news of the nurse's vacation are consistent with BPD.
Correct Answer is A
Explanation
A. Psychosocial history:
This includes information about the client's social, cultural, family, educational, and occupational background. It provides insights into the client's life circumstances, stressors, support systems, and overall psychosocial context. This information is crucial for understanding the context in which mental health symptoms may be occurring.
B. Vaccine history:
Vaccine history is not typically a primary factor in diagnosing mental health disorders. It is more relevant to preventive care and physical health.
C. History of allergies:
Allergies are primarily related to physical health and may not play a direct role in the diagnosis of mental health disorders.
D. Surgical history:
Surgical history is relevant to physical health conditions and is not a primary consideration in the diagnosis of mental health disorders.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today