A client has been admitted 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 nursing diagnosis for this client?

Ineffective health maintenance

Risk for other-directed violence

Risk for imbalanced nutrition

Risk for suicide

Answer and Explanation

The Correct Answer is C

A) Incorrect. While the client's sleep disturbance and lack of selfcare may contribute to
ineffective health maintenance, the more immediate concern is addressing the risk of imbalanced nutrition.

B) Incorrect. While clients in a manic state may exhibit hyperactivity and impulsivity, there is no indication in the scenario that the client poses an immediate risk for other-directed violence.

C) Correct. The client's reported lack of sleep and refusal to eat for an extended period raises concerns about nutritional deficits and dehydration. This is the most immediate and pressing issue to address.

D) Incorrect. While the client's manic state may increase the risk of impulsive behavior, there is no specific indication in the scenario that the client is at immediate risk for suicide.

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Correct Answer is C

Explanation

A. A depressant Depressants typically slow down the central nervous system, leading to
symptoms like sedation, slowed heart rate, and reduced blood pressure. The symptoms described in the question, such as tachycardia, hypertension, restlessness, and agitation, are not
characteristic of depressant use.

B. An opioid Opioids primarily lead to central nervous system depression, resulting in symptoms like respiratory depression, sedation, and decreased heart rate. The symptoms described in the question, such as tachycardia and restlessness, are not typical of opioid use.

C. A stimulant Stimulants, such as amphetamines or cocaine, lead to increased activity in the central nervous system, resulting in symptoms like tachycardia, hypertension, restlessness, and agitation. These symptoms align with the presentation described in the question.

D. An inhalant Inhalants can lead to a variety of effects, including dizziness, confusion, and sometimes increased heart rate. However, they are not typically associated with the specific symptoms of tachycardia, hypertension, restlessness, and agitation described in the question.

A. Determine what precipitates these hallucinations. B. Distract the client when hallucinating. C. Determine the content of the hallucinations. D. Let the client know you do not hear the voices.

Correct Answer is C

Explanation

A. While understanding precipitating factors is important, it is not the immediate priority when the client is actively experiencing hallucinations.
B. Distracting the client may not address the underlying cause of the hallucinations, which should be the priority.
C. Determining the content of the hallucinations can provide important information for assessment and intervention.
D. Dismissing the client's experience can be alienating and unhelpful.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted with tachycardia, hypertension, restlessness, agitation, and admits substance use. Which substance would be most likely to cause these symptoms?

Correct Answer is C

Explanation

What intervention is a priority when the client is experiencing auditory hallucinations?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. What information should be included in the teaching? (Select all that apply.)

A nurse suspects the client is experiencing delirium. Which of the following assessment findings would support the nurse's suspicion?

Which statement made by the nurse would be most appropriate to an elderly client who is confused, has no history of dementia and is hospitalized for an acute urinary tract infection?

Benztropine is ordered as needed (PRN) for a client taking haloperidol after being diagnosed with schizoaffective disorder. Which of the following assessments by the nurse would indicate a need for this medication?

A client is admitted to the emergency department after using ecstasy. The nurse identifies this drug as belonging to what class?

The nurse is caring for a client with poor self-esteem. What intervention would be important for the nurse to include in the plan of care?