A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis?
A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
C. Risk for suicide R/T powerlessness AEB insomnia and anorexia
D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
ANS: B
The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.
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Why is documentation of evaluation so crucial?
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The mother of a 5-year-old girl who shows clinging behavior and who becomes anxious when not with either parent asks how to help the child relax enough to go to sleep without staying beside the child's bed
The nurse could suggest that the mother do which of the following? A) Leave the door open so the child can hear the parents' voices while going to sleep. B) Set limits by insisting the child go to sleep and closing the door. C) Allow the child to fall asleep in the parents' bed, then carry her to her own bed after falling asleep. D) Teach her child to perform relaxation techniques.