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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: c. Document the client's verbatim statements.
Here's why the other options are wrong:
- a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
- b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
- d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.
Documenting the client's verbatim statements is the most important initial action because:
- It preserves the client's account of the assault in their own words.
- It allows for accurate reporting and investigation.
- It can be used as evidence in legal proceedings.
Here are some supporting points:
- The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
- The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]
In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.
Correct Answer is C
Explanation
Choice A rationale:
Joining a bowling league 2 months ago indicates that the client is actively seeking social interactions and engaging in activities. While grief can manifest in various ways, joining a social activity does not necessarily indicate maladaptive grief. It's important for individuals to find ways to connect with others and continue living their lives after the loss of a loved one.
Choice B rationale:
Meeting his daughter for dinner every week demonstrates ongoing communication and emotional connection with family. This behavior suggests a healthy attempt at maintaining relationships and coping with the loss. Regular interactions with family members can be supportive during the grieving process.
Choice C rationale:
Keeping his partner's closet untouched since her death is a sign of maladaptive grief. This behavior suggests an inability to let go of personal belongings and move forward after a significant period of time. In healthy grieving, individuals usually work through their emotions and gradually start reorganizing their living spaces and personal items.
Choice D rationale:
Exercising at a local health facility 3 days each week indicates that the client is engaging in self-care and maintaining physical health. While exercise can be a coping mechanism, this behavior alone does not provide enough evidence to determine whether the client is experiencing maladaptive grief.
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