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

Choice A rationale:

This response uses a confrontational tone and places blame on the client for their behavior, which is not an example of assertive communication. It can potentially escalate the situation and hinder effective communication.

Choice B rationale:

This statement is authoritarian in nature, using phrases like "you need to" and "forgive me," which can further upset the client and create a power struggle. It lacks empathy and understanding, making it ineffective for assertive communication.

Choice C rationale:

While this response acknowledges the consequences of the client's negative behavior, it uses commanding language ("you better go to your room"), which can be perceived as aggressive and may escalate the situation instead of facilitating effective communication.

Choice D rationale:

This statement is the most effective example of assertive communication. It acknowledges the client's feelings ("I understand that you are angry") while also asserting the nurse's adherence to protocol. This response demonstrates empathy, understanding, and a willingness to address the client's emotions in a non-confrontational manner.

A. A child who has a BMI indicating obesity. B. A child who uses the call light frequently. C. A child who has frequent visitors. D. A child whose parents answer questions for the child.

Correct Answer is D

Explanation

The correct answer is choice D. A child whose parents answer questions for the child.

Choice A rationale:A child with a BMI indicating obesity is not necessarily a sign of abuse. Obesity can result from various factors, including genetics, diet, and lifestyle. While it is important to address obesity for the child’s health, it does not directly indicate abuse.

Choice B rationale:A child who uses the call light frequently may be seeking attention or reassurance, but this behavior alone does not indicate abuse. Frequent use of the call light can be due to anxiety, fear, or a need for comfort, which can be addressed through appropriate nursing care and support.

Choice C rationale:A child who has frequent visitors is generally seen as having a strong support system. Frequent visits from family and friends usually indicate that the child is well-cared for and loved. This is not typically a sign of abuse.

Choice D rationale:A child whose parents answer questions for the child can be a red flag for abuse. This behavior may indicate that the parents are controlling and do not allow the child to speak for themselves, which can be a sign of emotional or psychological abuse. It is important for healthcare providers to observe interactions between the child and parents and assess for any signs of coercion or control.

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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 a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

Correct Answer is D

Explanation

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Correct Answer is D

Explanation

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 caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate that the client is experiencing maladaptive grief?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan?

A nurse is preparing to teach a client about the prescription of lithium (Eskalith) for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.).

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?

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

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?