An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

Document the threat in the medical record.

Inform the sister of the client’s threat.

Report the threat to the healthcare team.

Notify the healthcare provider of the threat.

Answer and Explanation

The Correct Answer is D

Choice A reason: Documenting the threat is important but less urgent than notifying the provider, who can initiate immediate safety measures for a client with bipolar disorder expressing harm intent. Notification ensures timely intervention, making documentation secondary and incorrect for the most important action.

Choice B reason: Informing the sister may breach confidentiality and is not the nurse’s role without legal or provider guidance. Notifying the provider ensures proper evaluation and safety planning, making this incorrect, as direct family notification is not the primary action in this scenario.

Choice C reason: Reporting to the healthcare team is less specific than notifying the provider directly, who can assess and manage the threat promptly. In bipolar disorder, rapid intervention is critical, making this less precise and incorrect compared to direct provider notification for immediate action.

Choice D reason: Notifying the healthcare provider is the most important action, as a threat to harm in bipolar disorder requires urgent evaluation for safety and potential mania-driven impulsivity. This ensures timely intervention, aligning with psychiatric safety protocols, making it the correct and most critical action.

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Correct Answer is B

Explanation

Choice A reason: Cancer screening, anger, gastritis, and daily intake are not part of the CAGE questionnaire, which focuses on cut down, annoyance, guilt, and eye-opener. These factors are unrelated to the validated screening tool, making this incorrect for exploring alcohol use based on CAGE criteria.

Choice B reason: The CAGE questionnaire screens for alcohol dependence by assessing efforts to cut down, annoyance when questioned, guilt about drinking, and using alcohol as an eye-opener. These directly identify problematic drinking patterns, aligning with addiction screening evidence, making this the correct choice for in-depth exploration.

Choice C reason: Consumption, liver enzymes, and gastrointestinal issues are relevant to alcohol use but not part of the CAGE questionnaire. CAGE focuses on behavioral indicators like guilt and annoyance. This choice includes non-CAGE criteria, making it incorrect for the screening tool’s specific focus.

Choice D reason: Minimizing drinking and missing family events are not CAGE criteria, though guilt is. The full CAGE framework (cut down, annoyance, guilt, eye-opener) better captures alcohol dependence. This choice is incomplete and includes non-CAGE items, making it incorrect for CAGE-based exploration.

A. Exhibits compulsive, ritualistic behaviors. B. Responds with illogical answers to questions. C. Admits to frequently thinking about committing suicide. D. Describes times of depression followed by feelings of euphoria. E. None F. None

Correct Answer is B

Explanation

Choice A reason: Compulsive, ritualistic behaviors are characteristic of obsessive-compulsive disorder, not schizophrenia. Schizophrenia involves disorganized thinking, often manifesting as illogical responses. Ritualistic behaviors are less typical, making this incorrect for identifying a behavior characteristic of schizophrenia in an acute care setting.

Choice B reason: Illogical answers reflect disorganized thinking, a core symptom of schizophrenia, particularly in acute phases. This is due to impaired thought processes, a hallmark of the disorder, aligning with psychiatric diagnostic criteria. This behavior is characteristic and observable during admission assessment, making it the correct choice.

Choice C reason: Suicidal thoughts may occur in schizophrenia but are not specific to it, as they appear in many psychiatric conditions. Illogical responses are more characteristic of schizophrenia’s cognitive disorganization. This choice is less precise, making it incorrect for a defining schizophrenia behavior.

Choice D reason: Depression followed by euphoria suggests bipolar disorder, not schizophrenia. Schizophrenia involves persistent psychotic symptoms like disorganized thinking, not mood swings. Illogical answers better represent schizophrenia’s thought disorder, making this incorrect for a characteristic behavior in an acute care schizophrenia admission.

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An adult female client with bipolar disorder is seen in the outpatient psychiatric clinic and tells the nurse that she is thinking of harming her sister. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Correct Answer is B

Explanation

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

Correct Answer is B

Explanation

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