A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?
Altered thought process related to hallucinations.
Risk for violence related to poor impulse control and judgement.
Altered thought process related to poor judgement.
Social isolation related to mania.
The Correct Answer is B
A. Altered thought process related to hallucinations: While altered thought processes are common in manic episodes, hallucinations are not typically associated with mania in Bipolar I disorder. Hallucinations are more commonly seen in psychotic disorders.
B. Risk for violence related to poor impulse control and judgment: This is the correct priority diagnosis. During a manic episode, individuals may have impaired impulse control and poor judgment, increasing the risk of impulsive and potentially violent behaviors. Ensuring the safety of the client and others is the priority.
C. Altered thought process related to poor judgment: While altered thought processes and poor judgment are characteristic of mania, the specific concern in this scenario is the potential for violence. The risk for violence takes precedence as a priority nursing diagnosis.
D. Social isolation related to mania: Social isolation may be a concern, but the immediate priority is addressing the risk for violence, as it poses a more significant threat to the client and others during a manic episode.
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Correct Answer is C
Explanation
A. Teaching clients about their illness: This function is within the scope of practice for both registered nurses and advanced practice psychiatric nurses. Registered nurses often provide education to clients about their illnesses, medications, and overall care.
B. Maintaining safety on the milieu: Both registered nurses and advanced practice psychiatric nurses are responsible for maintaining safety on the milieu. This includes monitoring the environment, assessing potential risks, and intervening to ensure the safety of clients and staff.
C. Prescribing medications: This function is exclusive to advanced practice psychiatric nurses, such as psychiatric nurse practitioners. Registered nurses do not have the authority to prescribe medications. Advanced practice psychiatric nurses receive additional education and training that allows them to prescribe medications as part of their role.
D. Administering medications: Registered nurses, including those specializing in psychiatric nursing, are authorized to administer medications. This is a common nursing function and does not require advanced practice authorization.
Correct Answer is B
Explanation
A. Generalized anxiety disorder and a nursing diagnosis of fear: Generalized anxiety disorder typically involves chronic, excessive worrying and anxiety that is not limited to specific situations or triggers. The sudden and intense symptoms described in the scenario, such as lightheadedness, tremulousness, diaphoresis, tachycardia, and dyspnea, are more indicative of a panic attack rather than generalized anxiety. The nursing diagnosis of fear may not fully capture the acute and intense nature of panic symptoms.
B. Panic disorder and a nursing diagnosis of panic anxiety: This is the correct answer. Panic disorder is characterized by recurrent, unexpected panic attacks, which align with the sudden onset of symptoms described in the scenario. The nursing diagnosis of panic anxiety is appropriate as it addresses the acute distress associated with panic attacks.
C. Pain disorder and a nursing diagnosis of altered role performance: There is no indication of pain being the primary issue in this scenario. The symptoms are more indicative of a panic attack rather than a pain disorder. Additionally, altered role performance is not a priority nursing diagnosis when addressing the acute symptoms of a panic attack.
D. Altered sensory perception and a nursing diagnosis of panic disorder: Altered sensory perception is not the primary issue in this scenario, and it does not specifically address the sudden and intense symptoms described. The focus should be on the panic symptoms and the associated distress, leading to the nursing diagnosis of panic anxiety.
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