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. The client's lethargy and lack of response to verbal commands raise concerns about their level of consciousness and potential airway compromise. Assessing the client's airway and breathing involves ensuring that the airway is clear, assessing respiratory rate and effort, and monitoring oxygenation.
B. Assessing the gag reflex can provide additional information about airway protection. However, it should not delay assessment and intervention for airway and breathing concerns.
C. Contacting the physician may be necessary but it is not the priority nursing action in this situation. The nurse should first assess the client's airway and breathing to ensure their safety and stability.
D. The client's lethargy and unresponsiveness are not normal findings after an endoscopy and require immediate assessment and intervention. Delaying assessment and intervention could lead to serious complications, including respiratory compromise or airway obstruction.
Correct Answer is C
Explanation
C. Individuals with schizotypal personality disorder often exhibit aloof and isolative behaviors, coupled with a bland and apathetic manner. This condition is characterized by significant discomfort in social situations, leading to avoidance and a lack of close relationships.
A. Individuals with this disorder may exhibit odd or peculiar behaviors, but they typically do not display manipulative or exploitative tendencies seen in other personality disorders, such as narcissistic personality disorder.
B. individuals with schizotypal personality disorder may display odd or eccentric behaviors but they are less likely to exhibit consistent patterns of generosity or selflessness.
D. Individuals with this disorder may be hypersensitive to criticism or perceived slights from others, which can lead to feelings of social anxiety or discomfort. However, social withdrawal is not a typical finding.

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