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. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.

B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.

C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.

D.A client diagnosed with mania who expressed active suicidal ideations

In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.

A. Did you take your medicine this morning? B. i'm sure the voices sound scary, I don't hear any voices speaking C. The devil only talks to people who are receptive to his influence D. You are not going to hell. You are a good person

Correct Answer is B

Explanation

A. "Did you take your medicine this morning?": While medication adherence is important, this response does not directly address the client's distress or validate their experience. It may come across as dismissive.

B. "I'm sure the voices sound scary, I don't hear any voices speaking.": This response acknowledges the client's experience without confirming or denying the presence of the voices. It expresses empathy and provides reassurance, fostering a therapeutic relationship.

C. "The devil only talks to people who are receptive to his influence": This response introduces a belief system that may not align with the client's reality and could be perceived as judgmental. It's important to avoid imposing personal beliefs on clients experiencing hallucinations.

D. "You are not going to hell. You are a good person": While expressing support and reassurance is positive, making definitive statements about the client's fate or goodness may not be helpful. It's more effective to acknowledge the distress without making absolute affirmations.

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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

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