A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

is not responding to other clients on the unit.

angrily argues with another client stating, "God is dead."

is refusing to take his prescribed mood stabilizer.

states, "There is no future when you feel so depressed."

Answer and Explanation

The Correct Answer is D

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

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Correct Answer is A

Explanation

A. Separation anxiety is primarily characterized by excessive distress or fear when separated from primary caregivers, and differences in parenting styles between the child's parents may affect the child's sense of security and exacerbate separation anxiety symptoms.
B. Separation anxiety is a common childhood anxiety disorder characterized by excessive worry or fear about separation from attachment figures, such as parents or caregivers. It is not typically associated with antisocial behavior
C. Separation anxiety is primarily related to the child's emotional response to separation from attachment figures and is not necessarily caused by environmental factors such as the organization of the home.

D. Prenatal stress may contribute to the child's overall risk for anxiety disorders. However, it is not a definitive predictor of separation anxiety in childhood.

A. denial. B. separation-individuation. C. splitting. D. reaction formation.

Correct Answer is C

Explanation

C. Splitting is characterized by viewing people and situations in extremes, either all good or all bad, without recognizing the complexity that usually exists in most circumstances. This black-and-white thinking can lead to rapidly shifting perceptions of others, as seen in the client's sudden change from idealizing the nurse to devaluing them.
A. Denial is a defense mechanism where the individual refuses to accept reality or acknowledge an aspect of reality that is apparent to others. In this scenario, the client is not denying any aspect of reality.
B. Separation-individuation is a developmental process where individuals establish autonomy and a sense of self separate from others, particularly from primary caregivers. This process is more relevant in infancy and early childhood.
D. Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or impulses. In this scenario, the client's expression of hatred towards the nurse does not appear to be a case of reaction formation, as there is no indication that the client actually harbors feelings of care or admiration towards the nurse.

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A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

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A nurse is caring for a 6-year old child suffering from separation anxiety. Which finding would a nurse expect when assessing the child? The child's:

Correct Answer is A

Explanation

The nurse has recently set limits for a client with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see that I was mistaken. You are hateful." This outburst can be assessed as:

Correct Answer is C

Explanation

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