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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Tardive dyskinesia is a side effect of long-term neuroleptic (antipsychotic) treatment. It is characterized by involuntary, repetitive movements, particularly of the face and tongue. This condition is more commonly seen in clients who have been on neuroleptics for extended periods.
B) Incorrect. Discontinuing neuroleptic treatment may lead to withdrawal symptoms or symptom recurrence, but it does not directly increase the risk of developing tardive dyskinesia.
C) Incorrect. Neuroleptic malignant syndrome (NMS) is a different side effect associated with neuroleptic medications, characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity.
D) Incorrect. Monoamine oxidase inhibitors (MAOIs) are a different class of medications and are not associated with the development of tardive dyskinesia.
Correct Answer is A
Explanation
A. "This therapy helps you learn to think more positively, and thereby reduce depressive
thoughts and symptoms." Cognitive behavioral therapy (CBT) aims to identify and challenge negative thought patterns and replace them with more positive and realistic thinking, which can help alleviate symptoms of depression.
B. "In this therapy, you will explore past events and analyze how these events have affected your behavior and thoughts." This description is more characteristic of psychodynamic therapy, not cognitive behavioral therapy.
C. "This type of therapy focuses on how you use defense mechanisms to feel more comfortable and content." This description aligns more with psychodynamic therapy, not cognitive behavioral therapy.
D. "The purpose of this therapy is to determine how to get psychological needs met through
interpersonal relationships." This statement does not accurately describe cognitive behavioral
therapy, which primarily focuses on identifying and changing maladaptive thought patterns and behaviors.
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