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) 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.

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.

A. Encourage participation in various physical activities. B. Encourage participation in a group card game. C. Encourage participation in a BINGO game. D. Encourage the creation of a new interactive game for the unit.

Correct Answer is A

Explanation

A) Correct. Encouraging participation in physical activities can help channel excess energy and agitation associated with manic episodes.

B) Incorrect. Group card games may not provide an outlet for the high energy level typically seen in a manic episode.

C) Incorrect. While Bingo is a social activity, it may not be sufficient to address the high energy and potential restlessness seen in a manic episode.

D) Incorrect. Creating a new interactive game may not be feasible or appropriate in the acute setting, and it may not effectively address the client's current needs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The client is experiencing a manic episode. Which of the following activities will be included in the plan of care?

Correct Answer is A

Explanation

An older adult in the middle and late stages of Alzheimer's forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family?

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?

What client population is at risk of developing tardive dyskinesia?

What are the possible physiological changes in the brain of a client diagnosed with Alzheimer's disease? (Select all that apply)

A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis. Which statement by the client shows an understanding of the medication?

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?

The nurse is obtaining the mental health history of a newly admitted client diagnosed with schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating?