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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Related Questions
Correct Answer is B
Explanation
A. Axons: Axons are nerve cell processes that transmit signals away from the cell body. While axons are essential for communication between nerve cells, their structure or function is not directly implicated in the altered behavior associated with schizophrenia.
B. Neurotransmitters: This is the correct answer. In schizophrenia, there is evidence of dysregulation in neurotransmitter systems, particularly dopamine. Dopamine dysregulation is associated with both positive and negative symptoms of schizophrenia. In the case of negative symptoms, such as social withdrawal and reduced emotional expression, hypoactivity in dopamine pathways may play a role.
C. Dendrites: Dendrites are nerve cell processes that receive signals from other neurons. Similar to axons, dendrites are crucial for communication between nerve cells, but their structure or function is not specifically implicated in the altered behavior associated with schizophrenia.
D. Synapses: Synapses are the junctions between nerve cells where neurotransmitters are released to transmit signals. While synapses play a critical role in neurotransmission, the altered behavior in schizophrenia is more closely linked to the dysregulation of neurotransmitters, particularly dopamine, than to structural changes in synapses.
Correct Answer is D
Explanation
A. Risperidone (Risperdal):
Risperidone is an atypical antipsychotic and generally has a lower propensity for causing anticholinergic side effects compared to typical antipsychotics.
B. Lithium (Lithobid):
Lithium is a mood stabilizer used primarily for bipolar disorder and does not typically cause anticholinergic side effects.
C. Buspirone (Buspar):
Buspirone is an anxiolytic medication and does not have significant anticholinergic properties. It tends to have fewer side effects compared to other medications used for anxiety.
D. Fluphenazine (Prolixin):
Fluphenazine is a typical antipsychotic medication and belongs to the phenothiazine class, which is known to have notable anticholinergic effects. These effects can include dry mouth, constipation, blurred vision, urinary retention, and cognitive impairment.
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