A client has been admited to a psychiatric-mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has been displaying manic symptoms for the past 2 weeks. The spouse reports that the client has not slept for the past 2 days and that the client has not eaten anything for at least 3 days. Which would be the priority for this client?
Imbalanced nutrition.
Risk for violence.
Ineffective health maintenance.
Risk for suicide.
The Correct Answer is A
Choice A reason: This is the correct choice. Given the client has not eaten for several days, addressing nutritional needs is a priority to prevent further physical health complications.
Choice B reason: While there may be a risk for violence, the immediate physical health needs related to nutrition are more pressing.
Choice C reason: Ineffective health maintenance may be a concern, but it is not as immediate as the risk posed by imbalanced nutrition.
Choice D reason: There is no indication in the text that the client is at risk for suicide; therefore, this would not be the priority without further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While it's important to provide support, simply telling the client they have nothing to be ashamed of does not address the underlying issues or feelings the client may be experiencing.
Choice B reason: This response opens a dialogue and allows the client to share their experiences and challenges since the last admission, fostering a therapeutic relationship and understanding.
Choice C reason: This statement could be perceived as judgmental and may make the client feel worse, potentially hindering the therapeutic relationship.
Choice D reason: Asking why they started drinking again could come across as accusatory and may cause the client to become defensive or feel guilty, which is not conducive to recovery.
Correct Answer is A
Explanation
Choice A reason: This statement clearly indicates the presence of auditory hallucinations, which are a common symptom of schizophrenia.
Choice B reason: While this could suggest auditory hallucinations, it could also be a question about shared experience and not necessarily indicative of a hallucination.
Choice C reason: Smelling feces where there is none could indicate an olfactory hallucination, which is less common than auditory hallucinations in schizophrenia.
Choice D reason: Tasting foul substances that are not present could suggest gustatory hallucinations, which, like olfactory hallucinations, are less common in schizophrenia.
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