A nurse on an in-patient unit received report at 15:00 hours. Which client should the nurse see first?
A client diagnosed I with hypomania who is speaking loudly on the unit.
A client diagnosed with hypomania who is complaining of pain.
A client with a history of mania who is pacing in the hallway
A client diagnosed with mania who expressed active suicidal ideations
The Correct Answer is D
A. A client diagnosed with hypomania who is speaking loudly on the unit: Hypomania involves elevated mood and increased activity, but it doesn't typically present an immediate risk of harm to self or others. While it may be disruptive, it doesn't have the same urgency as active suicidal ideation.
B. A client diagnosed with hypomania who is complaining of pain: Pain complaints should be addressed, but in the context of the given choices, it is not the highest priority. Assessing and addressing the potential for harm due to active suicidal ideation is more critical.
C. A client with a history of mania who is pacing in the hallway: Pacing in the hallway, while indicative of increased activity, does not necessarily indicate an immediate risk. The client expressing active suicidal ideations poses a more urgent concern that requires immediate attention.
D.A client diagnosed with mania who expressed active suicidal ideations
In determining priority, the nurse should consider the level of risk and the potential for harm to self or others. Suicidal ideation is a significant concern that requires immediate attention. A client expressing active suicidal thoughts poses an immediate risk to their safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Note escalating behaviors and intervene immediately:
This option prioritizes the client's safety by addressing escalating behaviors promptly. Bizarre behaviors, neologisms, and thought insertion may indicate a severe episode of psychosis, and timely intervention is crucial to prevent harm to the client or others.
B. Interpret attempts at communication:
While understanding and interpreting communication are important, in a situation with escalating behaviors and potential safety concerns, immediate intervention takes precedence. Communication interpretation can follow once the safety of the client has been ensured.
C. Assess for medication noncompliance:
Medication noncompliance can contribute to exacerbation of symptoms, but in an acute situation where safety is a concern, addressing immediate behaviors takes precedence. Medication assessment can be done in the context of a more comprehensive assessment after the immediate safety concerns have been addressed.
D. Assess triggers for bizarre, inappropriate behaviors:
Identifying triggers is important for understanding the underlying causes of the behavior, but in the context of escalating behaviors and potential safety issues, immediate intervention to de-escalate the situation is the priority. Triggers can be explored once the immediate safety concerns are addressed.
Correct Answer is D
Explanation
A. Social isolation R/T inability to relate to others
While social isolation may be a concern for individuals with paranoid personality disorder, the immediate safety risk associated with the disorder is more related to the potential for violence. Therefore, addressing the risk of violence takes precedence.
B. Risk for suicide R/T altered thought:
Paranoid personality disorder is not typically associated with a high risk of suicide. Individuals with this disorder are more likely to pose a risk to others due to their suspicious thoughts and mistrust. Suicide risk assessments are crucial but may not be the top priority in this specific case.
C. Altered sensory perception R/T increased levels of anxiety:
Paranoid personality disorder does involve heightened levels of anxiety, but altered sensory perception is not a primary characteristic of the disorder. Addressing anxiety is important, but the potential for violence toward others is a more immediate concern.
D. Risk for violence: directed toward others R/T suspicious thoughts:
This is the most appropriate priority. Individuals with paranoid personality disorder may have intense mistrust and suspicion, leading to the potential for aggressive or violent behavior directed toward others. Prioritizing safety and preventing harm to others is crucial in the care of clients with this disorder.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today