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. he CAGE questionnaire is a widely used screening tool for alcohol use disorder (AUD). It consists of four questions that assess the client's alcohol consumption, attempts to cut down or control drinking, feelings of guilt about drinking, and whether alcohol use interferes with daily activities or responsibilities.
B. The CIWA is a tool used to assess the severity of alcohol withdrawal symptoms in individuals with alcohol dependence who are undergoing detoxification or withdrawal management. The CIWA is not specifically used for screening alcohol use disorder but rather for monitoring and managing alcohol withdrawal symptoms in individuals with known alcohol dependence.
C. The AIMS is a tool used to assess for the presence and severity of abnormal involuntary movements, particularly those associated with antipsychotic medications or conditions such as tardive dyskinesia. It is not used for screening alcohol use disorder.

D. The ORT-OUD is a screening tool specifically designed to assess the risk of opioid use disorder (OUD) in individuals who are prescribed opioid medications for chronic pain. It is not used for screening alcohol use disorder.

A. ensures a good night's sleep." B. calms hyperactivity until the Lithium takes effect." C. cures manic symptoms." D. prevents extrapyramidal side effects."

Correct Answer is B

Explanation

B. Olanzapine is an antipsychotic medication commonly used to treat acute manic episodes in bipolar disorder. It can help to stabilize mood, reduce agitation, and calm hyperactivity while waiting for lithium to reach therapeutic levels and take effect.
A. Olanzapine is an antipsychotic medication that can have sedative effects and may help with sleep but this statement does not directly address the reason for its use in this specific situation.
C. Like other medications used to treat bipolar disorder, does not cure the condition. Instead, it helps to manage and stabilize symptoms, including manic episodes, by regulating neurotransmitter activity in the brain.
D. Olanzapine is an antipsychotic medication that has a lower risk of causing extrapyramidal side effects compared to typical antipsychotics but this statement does not accurately explain its use in this scenario.

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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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Naxlex Comprehensive Predictor Exams

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. Which screening tool should the nurse use to further evaluate this possibility?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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