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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ginkgo biloba has been reported to have anticoagulant properties and may potentiate the effects of warfarin, increasing the risk of bleeding. Therefore, individuals taking warfarin should exercise caution when using ginkgo supplements and be monitored closely for signs of bleeding or changes in anticoagulant response.
B. Dandelion is not known to directly affect blood clotting or the action of warfarin.
C. Acai berry is a fruit commonly consumed for its potential antioxidant properties and health benefits. There is limited scientific evidence regarding the interaction between acai and warfarin.
D. Zinc supplementation is generally considered safe for most individuals and there is limited evidence to suggest that zinc significantly enhances the anticoagulant effects of warfarin.
Correct Answer is ["C","D","E"]
Explanation
C. Identifying community resources is essential as it provides the client with accessible support during crises.
D. Educating the family about creating a safe and structured environment is also important because it involves the client's support system in their care, which can help prevent future crises.
E. Assisting the client in developing more effective coping mechanisms is vital for long-term management and recovery, as it empowers the client to handle stressors more healthily.
A. Isolating the client from all stressful situations is not practical or beneficial as it does not teach coping mechanisms or resilience.
B. Having a one-to-one sitter might be necessary in some inpatient settings but is not feasible or indicated for outpatient care.
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