A 30-year-old male patient, John, presents to the clinic with his wife. She reports that John has been experiencing periods of extreme energy and euphoria, followed by episodes of deep depression over the past several months. During his manic episodes, John engages in risky behaviors such as excessive spending and reckless driving. During his depressive episodes, he isolates himself and has expressed feelings of hopelessness. Based on this scenario, what is the priority nursing action for John?

Administer a mood stabilizer immediately.

Conduct a thorough assessment to evaluate John's safety and risk of harm to himself or others.

Schedule John for regular therapy sessions to manage his mood swings.

Educate John and his wife about the signs and symptoms of Bipolar Spectrum Disorder.

Answer and Explanation

The Correct Answer is B

Choice A reason: While mood stabilizers are essential in treatment, medication cannot be safely administered before completing an assessment of risk and safety.

Choice B reason: The priority in this scenario is to assess safety, as John is at risk of harming himself or others due to reckless behavior during mania and suicidal ideation during depression. Safety always precedes treatment or education.

Choice C reason: Therapy is a valuable part of long-term management, but it is not the immediate priority when safety concerns exist.

Choice D reason: Education is important but cannot come before determining immediate risk and ensuring safety.

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Correct Answer is D

Explanation

Choice A reason:Asking the client why he thinks the pain isn’t from hiking may come across as dismissive and could heighten his anxiety. It does not address his concerns constructively or facilitate a medical evaluation to determine the cause of the pain.

Choice B reason:Reassuring the client that bone cancer is unlikely without a medical evaluation is inappropriate, as it may minimize his concerns and delay necessary assessment. The nurse should avoid making diagnostic assumptions without provider input.

Choice C reason:Suggesting genetic testing is premature without a medical evaluation to determine if the pain warrants such testing. The client’s pain is likely related to hiking, and a provider’s assessment should guide any further diagnostic steps.

Choice D reason:Explaining that a provider will evaluate the client and determine the next steps is the most appropriate action. This response validates the client’s concerns, ensures a professional assessment of the knee pain, and provides a clear path forward without making assumptions about the cause.

A. The client states, "I see purple bugs crawling on the wall." B. The client states, "My heart is pounding out of my chest." C. The client tells the nurse he is a government agent. D. The client tells the nurse that he is too tired to attend the group meeting.

Correct Answer is B

Explanation

Choice A reason:Seeing purple bugs crawling on the wall suggests visual hallucinations, a symptom of schizophrenia rather than anxiety. Alprazolam, a benzodiazepine, is prescribed for anxiety, not psychotic symptoms, which are better managed with antipsychotics.

Choice B reason:A pounding heart is a physical symptom of anxiety, indicating heightened arousal or panic. This aligns with the indication for alprazolam, which is used to relieve acute anxiety symptoms, making it appropriate to consider administering the medication.

Choice C reason:Claiming to be a government agent may reflect a delusion, a symptom of schizophrenia. Alprazolam is not indicated for delusions, which require antipsychotic treatment, so this statement does not warrant its use.

Choice D reason:Feeling too tired to attend a group meeting suggests fatigue, not necessarily anxiety. Alprazolam is not indicated for tiredness, which may require other interventions like rest or medical evaluation, making this an inappropriate trigger for administration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

Correct Answer is B

Explanation

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

A patient with depression is prescribed sertraline 50 mg once daily. If the medication is administered for 14 days, what is the total dosage in milligrams?

A 45-year-old client with a delusional disorder believes that their neighbor is spying on them through hidden cameras in their home. The client is anxious but willing to discuss their belief. What is the most appropriate nursing response to support reality testing?

A nurse is caring for a client who is withdrawing from opioids. Which of the following medications should the nurse prepare to administer?

A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter, stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?

If a patient is prescribed 500 mg/day of Sertraline and the medication is available in 250 mg tablets, how many tablets should be administered each day?

A nurse is providing teaching for a client who has a new prescription for clozapine. Which of the following statements indicates the client understands the teaching?