The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Rationale:

A. "Let's discuss some weight loss strategies that might work for you.": While well-intentioned, this response shifts focus prematurely to problem-solving rather than acknowledging the client's immediate emotional distress. It can come across as dismissive of the client's feelings and reinforce stigma.

B. "Have you always felt uncomfortable being overweight?": This question delves into the client's history without first validating their current emotional state. It may seem intrusive and bypasses the opportunity to provide empathy in the moment.

C. "How long have you struggled with your weight?": This response centers on the weight issue rather than addressing the client’s expressed feelings of being stared at and judged. It risks making the client feel pathologized rather than supported.

D. “It sounds like you're saying that you feel uncomfortable around others.”: This therapeutic response reflects the client's feelings, validates their emotional experience, and encourages further expression. It helps build trust and demonstrates empathy without judgment.

Rationale:

A. A client who reports a sudden onset of dizziness when sitting up: Although concerning, dizziness on position change may indicate orthostatic hypotension and is not immediately life-threatening. This client requires monitoring but is not the top priority based on airway or circulatory compromise.

B. A client who has new onset urticaria and angioedema: New urticaria and angioedema suggest a potential anaphylactic reaction, which can quickly progress to airway obstruction. This is a life-threatening emergency requiring immediate intervention to secure the airway and administer epinephrine.

C. A client who has numerous rectal polyps and blood-tinged stools: This condition could indicate a colorectal condition such as polyposis or malignancy, but it is not acutely life-threatening. The client needs evaluation, but not before those with airway or circulatory risks.

D. A client who has a subluxation of the fifth digit on the left foot: A subluxation is a partial dislocation, which can be painful but does not involve vital organ systems. This musculoskeletal issue is stable and can be addressed after more urgent needs are met.