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 D
Explanation
Choice A reason: Implementing relaxation techniques is a helpful goal, but it does not directly address the compulsive behavior which is the focus of response prevention therapy.
Choice B reason: Understanding the benefits of deep breathing is beneficial, but it is not the primary goal of response prevention therapy.
Choice C reason: Confronting the trigger is part of the process, but the ultimate goal is to reduce anxiety associated with delaying or preventing the ritual.
Choice D reason: This is the correct choice. The primary goal of response prevention therapy is to reduce the anxiety associated with OCD rituals, making this the most appropriate goal.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. While anxiety can be a normal response to stress, the context implies that the client is experiencing more than a typical reaction.
Choice B reason: This choice is incorrect. Anxiety is not necessarily an abnormal response; it can occur in normal situations but becomes problematic when excessive.
Choice C reason: This choice is incorrect. While anxiety does have physiological components, the question seems to be asking about the experiential nature of anxiety.
Choice D reason: This is the correct choice. Anxiety is indeed a sense of psychological distress that can be triggered by stress but is characterized by excessive worry, fear, or apprehension.
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