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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. 24 hours is a long time for alcohol withdrawal symptoms to occur.
B. Alcohol withdrawal symptoms typically begin within 6 to 8 hours after the last drink for
individuals with a history of heavy alcohol use. These symptoms can range from mild anxiety and tremors to more severe symptoms like seizures and delirium tremens. It's crucial for
healthcare providers to monitor and manage alcohol withdrawal symptoms, as they can be life- threatening in severe cases.
C. Alcohol withdrawal symptoms occur within 6 to 8 hours, not 18 hours.
D. Alcohol withdrawal symptoms occur within 6 to 8 hours, not 72 hours.
Correct Answer is B
Explanation
A. Haloperidol is a first-generation antipsychotic and may not be as effective in addressing the negative symptoms (e.g., apathy, poverty of thought) as second-generation antipsychotics.
B. Olanzapine is a second-generation antipsychotic known to be effective in treating both positive and negative symptoms of schizophrenia.
C. Diphenhydramine is not typically used as a primary treatment for schizophrenia.
D. Chlorpromazine is a first-generation antipsychotic and may not be as effective in addressing the negative symptoms as second-generation antipsychotics.
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