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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Risperidone (Risperdal) is an atypical antipsychotic commonly used to manage symptoms of schizophrenia and bipolar disorder. It is not indicated for opioid withdrawal, making it an inappropriate choice.
Choice B rationale:
Lithium carbonate (Eskalith) is a mood stabilizer used primarily for bipolar disorder. It has no direct impact on opioid withdrawal symptoms, so it would not be the correct choice for managing opioid withdrawal.
Choice C rationale:
Disulfiram (Antabuse) is used to deter alcohol consumption by inducing unpleasant reactions when alcohol is consumed. It is not used to manage opioid withdrawal symptoms and is therefore not the correct choice.
Choice D rationale:
Methadone (Methadose) is a synthetic opioid agonist often used in medication-assisted treatment for opioid dependence and withdrawal. It helps alleviate withdrawal symptoms and cravings, promoting a smoother and safer withdrawal process.
Correct Answer is A
Explanation
Choice A rationale:
The nurse's approach of sitting with the client and offering simple, direct information is appropriate for a newly admitted client diagnosed with severe depression. This approach allows the nurse to establish a therapeutic rapport and provide the client with essential information in a clear and concise manner. People with severe depression often have difficulty processing complex information, so providing simple and direct information can enhance their understanding and alleviate any feelings of overwhelm.
Choice B rationale:
Explaining the unit policies and answering the client's questions might be overwhelming for someone with severe depression during their initial orientation. People experiencing depression often have difficulties with concentration and retaining information due to cognitive impairment. Presenting them with detailed policies and procedures might increase their anxiety and hinder their ability to absorb the information effectively.
Choice C rationale:
Having the client attend group therapy immediately might not be the best approach for someone with severe depression upon admission. Group therapy could be beneficial later in the treatment process, but initially, the client might not be emotionally ready to engage in group interactions. It's essential to establish a one-on-one therapeutic relationship and provide a stable environment before introducing them to group settings.
Choice D rationale:
Taking the client on a tour of the unit and introducing them to all the staff members on duty might be overwhelming and anxiety-inducing for someone with severe depression. It's crucial to approach the client with sensitivity and respect their emotional state. Introducing them to multiple staff members might increase their social anxiety and make them feel exposed, leading to further distress.
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