A nurse is collecting data from a client who has bipolar disorder with mania.
Which finding is the nurse’s priority?
The client gives personal items and money away to other clients.
The client is hostile and sarcastic towards the staff.
The client paces in the hallway during the day and most of the night.
The client demonstrates flight of ideas.
The Correct Answer is C
The correct answer is choice c. The client paces in the hallway during the day and most of the night.
Choice A rationale: Giving away personal items and money can indicate impulsivity and poor judgment, which are common in manic episodes. However, this behavior does not pose an immediate physical risk to the client or others.
Choice B rationale: Hostility and sarcasm towards staff can indicate irritability and agitation, which are also common in mania. While this behavior can disrupt the therapeutic environment, it is not the highest priority unless it escalates to physical aggression.
Choice C rationale: Pacing in the hallway during the day and most of the night indicates severe hyperactivity and potential exhaustion. This behavior poses a significant risk to the client’s physical health due to the possibility of dehydration, exhaustion, and other complications from lack of rest.
Choice D rationale: Demonstrating flight of ideas is a cognitive symptom of mania where the client rapidly shifts from one idea to another. While this can affect communication and thought processes, it does not pose an immediate physical risk.
In summary, the priority is to address behaviors that pose the greatest immediate risk to the client’s physical health and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.
Blurred vision and nausea are common early symptoms of lithium toxicity.
Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.
The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.
The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.
Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.
Choice A rationale:
Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.
It is important for the nurse to take more decisive action to prevent further toxicity.
Choice B rationale:
Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.
It is important for the nurse to take immediate action to protect the client's health.
Choice C rationale:
Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.
This is not a safe or appropriate action for the nurse to take in this situation.
Correct Answer is A
Explanation
Choice A rationale:
Concrete thinking is a cognitive distortion characterized by a rigid and literal interpretation of events and experiences. Individuals with concrete thinking often struggle to grasp abstract concepts, metaphors, or multiple perspectives. They tend to view situations in black-and-white terms, with little room for nuance or ambiguity.
Statement A, "I am aware that each problem has only one solution," exemplifies concrete thinking in several ways:
Absolute language: The use of the phrase "each problem has only one solution" suggests a fixed and inflexible mindset. It implies that there is only one correct way to approach any given problem, disregarding the possibility of alternative solutions or perspectives.
Oversimplification: The statement reduces the complexity of problem-solving to a single, definitive answer. It fails to acknowledge the multifaceted nature of most problems, which often require creative thinking, flexibility, and consideration of multiple factors.
Lack of abstract
Intolerance of ambiguity: Concrete thinkers often experience discomfort with uncertainty or open-ended situations. They prefer clear-cut answers and definitive conclusions, which can lead to frustration and anxiety when faced with complex or ambiguous problems.
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