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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Vomiting or diarrhea can lead to dehydration, which increases lithium levels in the blood, potentially causing toxicity. Instructing the client to notify their provider about these symptoms is critical for safe lithium use.
Choice B reason:Decreasing fluid intake to 1 liter per day is dangerous with lithium, as adequate hydration (typically 2–3 liters daily) is needed to prevent toxicity. This is incorrect advice.
Choice C reason:Excessive saliva is not a common side effect of lithium. More typical side effects include thirst, tremor, or weight gain, so this statement is inaccurate.
Choice D reason:Lithium can be taken with or without food, but taking it with food may reduce stomach upset. Advising it must be taken on an empty stomach is not necessary and could discourage adherence.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason:Tremors, particularly in the hands, are a common symptom of alcohol withdrawal, often appearing within hours of the last drink. They are caused by the nervous system’s hyperexcitability due to the absence of alcohol’s depressant effects, making this a key manifestation to include in teaching.
Choice B reason:Polyphagia, or excessive hunger, is not a typical symptom of alcohol withdrawal. Withdrawal is more commonly associated with loss of appetite or nausea due to gastrointestinal distress and nervous system dysregulation, so this should not be included in the teaching.
Choice C reason:Nystagmus, an involuntary eye movement, can occur in alcohol withdrawal, particularly in severe cases or during delirium tremens. It is a neurological symptom resulting from the brain’s response to withdrawal, making it appropriate to include in the teaching.
Choice D reason:Seizures are a serious and potentially life-threatening complication of alcohol withdrawal, often occurring within 12 to 48 hours after the last drink. Educating the client about this risk is critical, as it underscores the need for medical supervision during withdrawal.
Choice E reason:Illusions, or misinterpretations of sensory stimuli, are common in alcohol withdrawal, especially during severe stages like delirium tremens. These perceptual disturbances should be included in the teaching to prepare the client for possible symptoms.
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