A nurse in an acute mental health unit is admitting a client who has bipolar disorder.
Which of the following findings supports the admitting diagnosis of acute mania?
The client's spouse reports that the client has recently gained weight.
The client responds to questions with disorganized speech.
The client reports that voices are telling him to write a novel.
The client is dressed in all black.
The Correct Answer is B
Choice A rationale:
Weight gain is not typically associated with acute mania in bipolar disorder.
Choice B rationale:
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
Choice C rationale:
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
Choice D rationale:
Dressing in all black is not a specific symptom of acute mania.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.
Choice B rationale:
Lip smacking and tongue thrusting are not typically associated with lithium toxicity.
Choice C rationale:
While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.
Choice D rationale:
Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.
Correct Answer is D
Explanation
Choice A rationale:
While educating the client about policies upon admission to the unit is important, it may not have the greatest impact on both the management of care and on milieu environment.
Choice B rationale:
Instructing the client that intrusive behaviors are not appropriate is important, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice C rationale:
Ensuring that the client’s medication therapy is administered in a timely manner is crucial, but it may not have the greatest impact on both the management of care and on milieu environment.
Choice D rationale:
Setting and maintaining consistent unit policies that are enforced by all staff can create a stable and predictable environment, which can have a significant impact on both the management of care and on milieu environment.
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