A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?
A Client diagnosed with hypomania who is speaking loudly on the unit
A client diagnosed with mania who expressed active suicidal ideations
A client with a history of mania who is pacing in the hallway
A client diagnosed with hypomania who is complaining of pain
The Correct Answer is B
Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.
B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.
C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.
D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
While all the outcomes are important in the overall care of a client with bipolar disorder, the safety of the client takes precedence, especially during the acute phase of the disorder. Bipolar disorder is characterized by mood swings that can include episodes of mania, which may involve risky behaviors or even thoughts of self-harm.
A. The client will remain safe throughout hospitalization: This is the priority outcome. Ensuring the safety of the client during hospitalization involves monitoring for any signs of self-harm or harm to others, managing any acute manic or depressive symptoms, and providing a secure environment.
B. The client will accomplish activities of daily living independently by discharge: While independence in activities of daily living is a valuable outcome, it may not be the immediate priority during the acute phase of bipolar disorder. Addressing safety and stabilization come first.
C. The client will use problem-solving to cope adequately after discharge: Coping skills are important for long-term management, but ensuring safety and stabilization during the hospitalization phase takes precedence. Coping skills can be addressed as part of the overall treatment plan.
D. The client will verbalize feelings during group sessions by discharge: Expression of feelings is an important aspect of mental health treatment, but safety and stabilization remain the priority, especially during the acute phase of bipolar disorder.
Correct Answer is C
Explanation
A. Concrete thinking: Concrete thinking refers to a style of thinking that is focused on immediate and literal aspects of information. The patient's statement involves more than concrete thinking; it includes an irrational belief about the consequences of contagious bacteria, indicating a distorted perception of reality.
B. Agitation: Agitation refers to a state of restlessness or increased activity. The patient's statement does not necessarily reflect agitation but rather a specific paranoid belief about the consequences of bacteria exposure.
C. Paranoia: This is the correct answer. Paranoia involves irrational thoughts and fears of being harmed or persecuted by others. The patient's belief that contagious bacteria are everywhere and will lead to being locked up with other infected people is indicative of paranoid ideation.
D. Poverty of thought: Poverty of thought is characterized by a lack of meaningful or detailed thought content. The patient's statement is not an example of poverty of thought; rather, it involves specific and elaborate content related to a paranoid belief.
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