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.
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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Related Questions
Correct Answer is C
Explanation
Choice A reason:A close friend can offer emotional support, but they may lack the training to address the complex medical, legal, and psychological needs of a sexual assault survivor in the immediate aftermath.
Choice B reason:A chaplain can provide spiritual support, which may be helpful for some clients. However, immediate needs like medical care, evidence collection, and crisis intervention require specialized expertise.
Choice C reason:A social worker is trained to provide crisis intervention, coordinate medical and legal resources, and offer emotional support tailored to trauma survivors. They are the most effective resource immediately following a sexual assault to address comprehensive needs.
Choice D reason:A psychologist can provide long-term mental health support, but immediate post-assault care prioritizes crisis intervention, medical evaluation, and legal coordination, which are better handled by a social worker.
Correct Answer is B
Explanation
Choice A reason: Delayed menarche at age 13 is within normal developmental variation. Although it may cause concern for the adolescent, it is not an immediate priority unless accompanied by other signs of delayed puberty.
Choice B reason: Expressing social isolation and rejection is a priority because it may indicate depression or risk for self-harm. Adolescents who feel excluded and disliked are more vulnerable to mental health crises.
Choice C reason: Perceiving parents as overprotective is common in adolescence as teenagers seek independence. This is not typically a clinical concern.
Choice D reason: Concerns about acne and appearance are common during adolescence and usually reflect normal developmental self-consciousness rather than a safety issue.
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