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 C

Explanation

C. Administering naloxone is often the priority action for a client exhibiting symptoms of opiate intoxication, especially if they are experiencing significant respiratory depression or unconsciousness. Naloxone is a medication used to rapidly reverse the effects of opioids, including respiratory depression and sedation.
A. Opening the crash cart is not the priority action for a client exhibiting symptoms of opiate intoxication unless the client's condition deteriorates rapidly, leading to a life-threatening emergency such as respiratory depression or cardiac arrest.
B. This intervention is important for clients experiencing respiratory depression, hypoxemia, or altered mental status due to opiate overdose. However, it may not be the highest priority action if the client's respiratory status is stable
D. Contacting the client's parents or guardians is important for obtaining medical history, consent for treatment (if applicable), and support. However, it may not be the highest priority action in the immediate management of opiate intoxication.

A. a 1-year-old child who has a dislocated shoulder from arm swinging. B. several visits of the same child with varied injuries. C. a 5-year-old child who broke his arm and clings to mother crying D. repeated visits of the same child with middle ear infections.

Correct Answer is B

Explanation

B. Multiple visits of the same child with different injuries could be a significant red flag for possible child abuse. Patterns of repeated injuries or injuries inconsistent with the child's developmental stage or reported activities may indicate a pattern of maltreatment.
A. While accidental injuries can occur, a dislocated shoulder in a 1-year-old child from arm swinging seems unlikely and may warrant further investigation.
C. Breaking a bone, such as an arm, can occur accidentally during childhood play or activities and the behavior of the child clinging to the mother is expected in moments of pain.
D. Middle ear infections are common in childhood and typically do not raise suspicion of abuse on their own.

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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 in the Emergency Department (ED) assesses a 17-year-old client exhibiting symptoms of opiate intoxication. Which of the following should be the nurse's priority action?

Correct Answer is C

Explanation

Several children are seen in the ER for treatment of illnesses and injuries daily. The situation that would cause the nurse to have a high suspicion of child abuse would be:

Correct Answer is B

Explanation

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