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 A

The correct answer is Choice A.

Choice A rationale: Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. Clients may exhibit pressured speech, tangentiality, and flight of ideas, reflecting the heightened energy and cognitive disruptions associated with manic episodes.

Choice B rationale: Reporting auditory hallucinations, such as voices telling the client to write a novel, is more indicative of a psychotic disorder rather than acute mania in bipolar disorder. Mania typically involves elevated mood and activity levels, not hallucinations.

Choice C rationale: Weight gain reported by the spouse is not specific to acute mania. While changes in appetite and weight can occur in bipolar disorder, they are not defining features of manic episodes, which are characterized by heightened mood and activity.

Choice D rationale: Being dressed in all black does not specifically indicate acute mania. Mania is characterized by mood disturbances and increased activity levels rather than specific choices in clothing color, which can vary widely among individuals.

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Correct Answer is D

Explanation

The correct answer is choice D: Continuous worry about the undiagnosed presence of an illness.

Choice A rationale:

Sudden unexplained loss of peripheral sensation is not typically associated with illness anxiety disorder. This symptom may be indicative of a neurological condition and would require further medical evaluation to determine the cause.

Choice B rationale:

Obsession over a fictitious defect in physical appearance is more characteristic of body dysmorphic disorder, not illness anxiety disorder. Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance, which are not observable or appear slight to others.

Choice C rationale:

Having prior physical health followed by the need for two surgeries within the last three months does not necessarily indicate illness anxiety disorder. This choice does not provide enough context to link it to illness anxiety disorder, as it could be related to many other health conditions.

Choice D rationale:

Continuous worry about the undiagnosed presence of an illness is a key finding in illness anxiety disorder. Individuals with this disorder are excessively concerned with and preoccupied by the belief that they have, or are in danger of developing, a serious undiagnosed illness despite medical reassurance.

A. The client took an overdose of the medication. B. The client experienced a common side effect of the medication. C. The client demonstrated an allergic response to the medication. D. The client consumed alcohol while taking the medication.

Correct Answer is D

Explanation

Choice A rationale:

The client taking an overdose of the medication is unlikely to be the cause of the symptoms. Disulfiram (Antabuse) is a medication used to treat alcohol dependence by causing adverse effects when alcohol is consumed. However, an overdose would not result in severe nausea and vomiting as described.

Choice B rationale:

Experiencing common side effects of the medication is a possibility, but severe nausea and vomiting are not typical side effects of disulfiram. The medication's primary purpose is to induce unpleasant effects when alcohol is consumed, not to cause severe gastrointestinal symptoms.

Choice C rationale:

Demonstrating an allergic response to the medication could potentially cause various symptoms, but severe nausea and vomiting are not commonly associated with allergies to disulfiram. Allergic reactions often manifest as skin rashes, itching, and respiratory symptoms, which are not described in this scenario.

Choice D rationale:

The correct choice. Disulfiram works by inhibiting alcohol metabolism, leading to the accumulation of acetaldehyde, a toxic substance, when alcohol is consumed. This buildup of acetaldehyde results in unpleasant symptoms like severe nausea, vomiting, headache, and flushing. Since the client has recently started taking disulfiram and reports experiencing severe nausea and vomiting after discontinuing the medication, it is most likely that the client consumed alcohol while taking the medication, triggering the adverse reaction.

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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 is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication the client is in the denial phase of the grief process?

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A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

A nurse is admitting an older adult client to the unit who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?