A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

The patient is demonstrating signs of ineffective coping and should be referred for psychiatric evaluation

The patient is showing symptoms of major depressive disorder and requires immediate intervention

The patient is noncompliant with medical care due to unresolved emotional issues

The patient is progressing through the normal stages of grief

Answer and Explanation

The Correct Answer is A

Choice A reason: Withdrawn behavior and avoiding eye contact suggest ineffective coping, as the patient struggles to process missing a treatment. Psychiatric evaluation can assess underlying emotional distress, such as anxiety or depression, and provide targeted interventions, making this the correct choice for addressing the patient’s needs.

Choice B reason: Symptoms like withdrawal could suggest depression, but diagnosing major depressive disorder requires more criteria, such as persistent low mood or anhedonia, not evident here. Immediate intervention assumes severity not supported by the scenario, making this choice less accurate than a referral.

Choice C reason: Labeling the patient as noncompliant assumes intentional refusal, but the scenario suggests emotional distress, not deliberate nonadherence. Withdrawal and avoidance indicate psychological barriers, not noncompliance, making this choice incorrect for the described behavior.

Choice D reason: Normal grief involves stages like denial or sadness, but the scenario lacks evidence of a loss triggering grief. Withdrawal and avoidance suggest coping difficulties, not a clear grief process, making this choice incorrect for the patient’s presentation.

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Correct Answer is A

Explanation

Choice A reason: Labile affect, common in bipolar disorder, involves rapid, unpredictable shifts in emotional expression, such as moving from laughter to crying. This reflects dysregulation in the limbic system and prefrontal cortex, leading to exaggerated emotional responses. The sudden mood swings described align with this condition, making it the correct choice.

Choice B reason: Flat affect describes a severe reduction or absence of emotional expression, often seen in schizophrenia or severe depression. Patients display minimal facial or vocal changes, unlike the rapid emotional shifts in the scenario. This lack of emotional variability does not match the described behavior, making this choice incorrect.

Choice C reason: Restricted affect refers to a limited range of emotional expression, less severe than flat affect, often seen in mood disorders or personality disorders. It does not involve rapid shifts between emotions, as described in the question, but rather a consistently narrowed emotional range, making this choice incorrect.

Choice D reason: Blunted affect involves a reduced intensity of emotional expression, common in schizophrenia or post-traumatic stress disorder. Patients show muted responses, not rapid shifts between intense emotions like laughter and crying. This does not align with the described bipolar disorder behavior, making this choice incorrect.

A. I must check with the physician first to approve releasing this information. B. I cannot share that information without the patient’s consent. C. Only immediate family members are allowed to receive medical updates. D. I’d be happy to provide an update on the medications and care plan.

Correct Answer is D

Explanation

Choice A reason: Checking with the physician before releasing information to a legal guardian is unnecessary, as guardians have legal authority to access patient information. This response delays care coordination and disregards the guardian’s role, potentially hindering decision-making, making it incorrect.

Choice B reason: Requiring patient consent is inappropriate for a patient with advanced Alzheimer’s, who lacks decision-making capacity. The court-appointed guardian has legal authority to receive medical information, as they act in the patient’s best interest, making this response incorrect.

Choice C reason: Restricting information to immediate family ignores the legal guardian’s authority. Guardians, regardless of family status, are legally entitled to medical updates to make informed care decisions, as they represent the patient’s interests, making this response incorrect.

Choice D reason: Providing the guardian with medication and care plan updates is appropriate, as they have legal authority to make healthcare decisions for the patient. This ensures informed decision-making and complies with legal and ethical standards, making this the correct choice.

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A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes a patient with bipolar disorder who suddenly shifts from laughing joyfully to crying within minutes during the therapy session. This sudden and intense change in emotional expression is an example of:

Correct Answer is A

Explanation

An elderly patient with advanced Alzheimer’s disease is admitted to the unit. The nurse is informed that the patient has a court-appointed legal guardian. The guardian arrives and asks for information about the patient’s medications and plan of care. What is the nurse’s best response?

Correct Answer is D

Explanation

What is waxy flexibility in psychiatric patients?

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A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

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