A nurse on an in-patient unit received the report at 15:00 hours. Which client should the nurse see first?
A Client diagnosed with hypomania who is speaking loudly on the unit
A client diagnosed with mania who expressed active suicidal ideations
A client with a history of mania who is pacing in the hallway
A client diagnosed with hypomania who is complaining of pain
The Correct Answer is B
Client diagnosed with hypomania who is speaking loudly on the unit: While hypomanic individuals may exhibit increased energy and talkativeness, the urgency is lower compared to a client expressing active suicidal ideations. This client does not pose an immediate threat to themselves or others.
B. Client diagnosed with mania who expressed active suicidal ideations: This is the correct answer. A client with active suicidal ideations is at an elevated risk and requires immediate attention. Suicidal thoughts in the context of mania can be impulsive, and prompt intervention is crucial to ensure the client's safety.
C. Client with a history of mania who is pacing in the hallway: Pacing may be a symptom of mania, but without additional information about the client's current state and any potential immediate risks, the client expressing active suicidal ideations takes precedence.
D. Client diagnosed with hypomania who is complaining of pain: Pain complaints, in the absence of other urgent factors, do not take precedence over active suicidal ideations. The risk of harm to oneself or others is a higher priority.
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Related Questions
Correct Answer is D
Explanation
A. Limit time for the client to perform activities:
This option may increase agitation and frustration for the client with Alzheimer's disease. It is generally not recommended to limit their time for activities, as it may lead to distress.
B. Rotate assignment of daily caregivers:
Consistency in caregivers is often beneficial for individuals with Alzheimer's disease. Constantly changing caregivers can lead to confusion and anxiety for the client. Thus, rotating caregivers is not the best approach.
C. Provide an activity schedule that changes from day to day:
Individuals with Alzheimer's disease often benefit from routine and predictability. Changing the activity schedule daily can cause confusion and disorientation. Therefore, it is not the most appropriate intervention.
D. Talk the client through tasks one step at a time:
This is the best choice because breaking down tasks into simple, manageable steps can help individuals with Alzheimer's disease understand and follow instructions. It promotes a sense of accomplishment and reduces frustration. This approach is aligned with the principles of dementia care.
Correct Answer is A
Explanation
Orientation: When a nurse asks a client to identify their name, date, residential address, and situation, they are assessing the client's orientation. Orientation refers to an individual's awareness of time, place, person, and situation.
B. Affect: Affect refers to the observable expression of emotions. It involves the client's emotional tone, such as being happy, sad, angry, or flat. It is not directly assessed by asking about personal information.
C. Perception: Perception involves the way individuals interpret and make sense of sensory information. Asking about personal information is more related to orientation than perception.
D. Mood: Mood refers to a more sustained emotional state. It is not directly assessed by asking for specific personal information about the current situation or location.
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