Difficulty: Medium
Average Score: 85%
Simulated
A client has been admitted to a psychiatric-mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has not slept for the past 2 days and that the client has not eaten anything for at least 3 days. Which would be the priority for this client?
Correct answer
A
Rationale
The correct answer is A: Imbalanced nutrition. In this scenario, the client's lack of sleep and food intake for several days poses an immediate threat to their physical health. Adequate nutrition is essential for overall well-being, and the client's current state of not eating for 3 days can lead to severe complications. Addressing imbalanced nutrition should be the priority to stabilize the client's physical health before addressing other concerns. Other choices such as risk for violence, ineffective health maintenance, and risk for suicide are important considerations but addressing the client's immediate physical needs for nutrition takes precedence in this situation.