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 A

Explanation

Choice A rationale:

(Correct) Severe anxiety can lead to a fight-or-flight response, which might manifest as aggressive behavior. The individual might feel threatened and react defensively, potentially displaying aggressive actions to protect themselves.

Choice B rationale:

Attention-seeking conduct is less likely to be a primary manifestation of severe anxiety. While individuals with anxiety might seek reassurance or attention, the level of anxiety described here is more likely to evoke a defensive response rather than attention-seeking behavior.

Choice C rationale:

Mild fidgeting can be a manifestation of anxiety, but in the context of severe anxiety, the physical symptoms are often more pronounced, including restlessness, trembling, and muscle tension.

Choice D rationale:

Mild difficulty problem-solving is less likely to be a prominent manifestation of severe anxiety. Severe anxiety tends to affect the individual's ability to function and cope, leading to more intense and immediate reactions.

A. Medicate the client with a sedative. B. Have the client join a therapy group. C. Suggest that the client rest in bed. D. Remain with the client in his room for a while.

Correct Answer is D

Explanation

The correct answer is choice D: "Remain with the client in his room for a while."

Choice D rationale:

This choice is the correct answer because when a client is experiencing panic-level anxiety, their immediate need is for support and reassurance. Staying with the client helps establish a sense of safety and demonstrates the nurse's presence, which can help reduce anxiety. Providing a calming and supportive presence is a therapeutic nursing intervention in this situation.

Choice A rationale:

Medicating the client with a sedative might be appropriate in some cases of severe anxiety, but it should not be the first action taken. Non-pharmacological interventions, such as offering emotional support, should be prioritized before resorting to medication.

Choice B rationale:

Joining a therapy group might be beneficial for the client in the future, but during the acute phase of panic-level anxiety, the client might not be in a state to actively participate and engage in group therapy. Immediate individual attention is necessary.

Choice C rationale:

While suggesting that the client rest in bed could be helpful for relaxation, it might not be sufficient to address the intensity of panic-level anxiety. The client might not be able to rest or calm down without more direct support from the nurse.

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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 at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

Correct Answer is A

Explanation

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?

Correct Answer is D

Explanation

Exhibit. The spouse of a male client with early-stage Alzheimer's disease (AD) tells the nurse, "I am just exhausted from the constant worry. I don't know what to do." Which action is best for the nurse to take next? (Select All That Apply.)

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