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.

Answer and Explanation

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 ["B","C","D"]

Explanation

A. Challenge the patient at all times and remain in control of the situation:

Explanation: While maintaining a therapeutic boundary and structure is essential, challenging the patient at all times may lead to resistance or defensiveness. Collaborative and supportive approaches are often more effective than confrontational ones.

B. Provide clear and straightforward communication:

Explanation: Individuals with personality disorders may struggle with interpersonal relationships and communication. Clear and straightforward communication helps to minimize misunderstandings and establish a therapeutic environment.

C. Hold persons accountable for their actions:

Explanation: Accountability promotes responsibility and encourages individuals with personality disorders to take ownership of their behaviors. Setting clear expectations and consequences can be beneficial in fostering a sense of responsibility.

D. Remain consistent:

Explanation: Consistency in approach, rules, and expectations is crucial when working with individuals with personality disorders. It helps establish a stable and predictable environment, promoting a sense of security for the individual.

E. Avoid being too nice or friendly:

Explanation: Avoiding being too nice or friendly doesn't mean being unkind or dismissive. A balanced and professional approach, combining empathy with clear boundaries, is more beneficial. Being overly nice or friendly may blur professional boundaries and hinder therapeutic progress.

A. Mental health and mental illness are the same concepts B. "Mental health can present at any age, whereas mental illness can only present after age 20 C. Mental illness is when there is a disruption in a person’s ability to complete activities of daily living, whereas mental health is when the person can cope with daily stressors D. Mental illness is a condition caused by poor mental health

Correct Answer is C

Explanation

A. Incorrect. Mental health and mental illness are not the same concepts. Mental health refers to a person's emotional, psychological, and social well-being, while mental illness refers to specific mental health conditions that significantly affect a person's thoughts, emotions, and behaviors.

B. Incorrect. Mental health and mental illness can both present at any age. Mental health is a broader concept that encompasses overall well-being, while mental illnesses can manifest at various stages of life.

C. Correct. This statement accurately distinguishes between mental health and mental illness. Mental health involves the ability to cope with daily stressors, while mental illness is characterized by disruptions in activities of daily living due to specific mental health conditions.

D. Incorrect. This statement confuses the relationship between mental health and mental illness. Mental health is a broader concept that contributes to overall well-being, while mental illness is a specific condition that may arise due to various factors, including poor mental health.

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A newly admitted client diagnosed with Bipolar I is experiencing an acute manic episode. Which nursing diagnosis is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When working with individuals who have a personality disorder. The nurse is aware of the importance of incorporating which nursing measures. (Select all that apply).

Correct Answer is ["B","C","D"]

Explanation

A nurse is discussing the difference between mental illness and mental health with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding?

Correct Answer is C

Explanation

A nurse is describing the concept of cultural competence to a newly licensed nurse. Which of the following examples should the nurse include?

Within the nurse's scope of practice, which function is exclusive to the advanced practice psychiatric nurse?

What is the purpose of a nurse gathering client information?

A nurse is reviewing the medical record of a client who has a new prescription for clozapine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to clozapine?

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize which client statement would provide supportive evidence of this symptom?

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

A nurse is teaching about sources of psychological stress to a group of newly licensed nurses. The nurse should identify which of the following qualifies as a source of psychological distress?

A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?