A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?

Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss

Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

Knowledge deficit R/T bipolar disorder AEB concern about symptoms

Risk for suicide R/T powerlessness AEB insomnia and anorexia

Answer and Explanation

The Correct Answer is A

A. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss: This is the correct priority nursing diagnosis. The client's significant weight loss is indicative of altered nutrition and poses a more immediate threat to their well-being. Addressing the nutritional deficit takes precedence to ensure the client's physical health and stability.

B. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights: While altered sleep patterns are a concern, the priority in this scenario is the significant weight loss, which is indicative of altered nutrition. Nutritional deficits can have more immediate health consequences.

C. Knowledge deficit R/T bipolar disorder AEB concern about symptoms: While addressing knowledge deficits is important for the client's understanding of their condition, the immediate concern is the client's significant weight loss. Nutritional deficits can lead to serious health issues and should be addressed as a priority.

D. Risk for suicide R/T powerlessness AEB insomnia and anorexia: While the client's symptoms may contribute to a risk for suicide, the immediate focus should be on addressing the altered nutrition, which is a more direct threat to the client's physical health.

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Correct Answer is D

Explanation

A. Implement the client's behavioral modification plan:

While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.

B. Document the size and location of the cuts:

Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.

C. Administer a tetanus antitoxin:

Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.

D. Inspect the cuts for debris:

This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.

A. Allow the client to pace alone until physically tired B. Walk with the client at a gradually slower pace C. Have a staff member escort the client to her room D. Instruct the client to sit down and stop pacing

Correct Answer is B

Explanation

A. Allow the client to pace alone until physically tired: While pacing can be a coping mechanism, leaving the client alone may not be the most therapeutic approach. It is important for the nurse to provide support and assess the client's emotional state.

B. Walk with the client at a gradually slower pace: This is the correct answer. Walking with the client at a gradually slower pace allows the nurse to offer support and engage in therapeutic communication. It provides a calming presence and can assist the client in self-regulating their anxiety.

C. Have a staff member escort the client to her room: Escorting the client to her room might be perceived as restrictive or punitive. It is generally more beneficial to engage in supportive interventions and encourage coping strategies.

D. Instruct the client to sit down and stop pacing: Giving direct orders to stop pacing may increase anxiety and may not be an effective approach. It is often better to engage in a supportive manner and explore ways to help the client manage their anxiety.

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A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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