A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

The client responds to questions with disorganized speech.

The client reports that voices are telling him to write a novel.

The client's spouse reports that the client has recently gained weight.

The client is dressed in all black.

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. The client reports that voices are telling him to write a novel.

Choice A rationale:

The client responds to questions with disorganized speech. Disorganized speech is a characteristic of schizophrenia and can be present in acute mania as well. However, in this scenario, the client's speech is not described as disorganized. Instead, the client's experience is centered around auditory hallucinations.

Choice B rationale:

The client reports that voices are telling him to write a novel. Auditory hallucinations are a common feature of acute mania and can involve hearing voices that instruct or command the individual to perform certain actions. The client's belief that voices are compelling them to write a novel aligns with this characteristic.

Choice C rationale:

The client's spouse reports that the client has recently gained weight. Weight gain is not a specific symptom of acute mania. While changes in appetite and weight can occur during manic episodes, they are not a defining characteristic for diagnosing acute mania.

Choice D rationale:

The client is dressed in all black. Unusual or eccentric clothing choices can sometimes be seen in individuals with manic episodes, as their behavior and judgment can be impaired. However, dressing in all black is not a definitive indicator of acute mania and does not support the diagnosis on its own.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.

Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.

Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.

Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.

A. Warn the client that further disruptions will result in seclusion. B. Ignore the client's behavior, realizing it is consistent with her illness. C. Ask the client to recommend consequences for her disruptive behavior. D. Set limits on the client's behavior and be consistent in approach.

Correct Answer is D

Explanation

Choice D rationale:

Setting limits on the client's behavior and maintaining consistency is essential when dealing with a client experiencing a manic episode. Manic episodes are characterized by impulsive and often disruptive behaviors. By setting clear limits, the nurse establishes boundaries that help manage the disruptive behavior and maintain a safe and therapeutic environment. Consistency in approach is vital to avoid confusion and to provide the client with a sense of stability during a time when their judgment and impulse control might be impaired.

Choice A rationale:

Warning the client that further disruptions will result in seclusion might escalate the situation and potentially worsen the client's agitation. It's crucial to use non-confrontational approaches when dealing with clients experiencing manic episodes to prevent increased agitation and aggression.

Choice B rationale:

Ignoring the client's behavior is not a suitable approach, as it could lead to a deterioration of the situation and potentially compromise the safety and well-being of both the client and others on the unit. It's important to address disruptive behavior promptly and appropriately.

Choice C rationale:

Asking the client to recommend consequences for her disruptive behavior might not be effective during a manic episode. Clients in a manic state might not have a realistic or rational perspective on their behavior, and involving them in determining consequences could lead to unreasonable outcomes.

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A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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