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 D
Explanation
Choice A rationale:
Encouraging family to take the client out of the facility for short periods of time can be beneficial, but it does not address the sudden change in behavior.
Choice B rationale:
Rewarding the client for her change in behavior can reinforce positive behavior, but it does not address the sudden change in behavior.
Choice C rationale:
Asking the client why her behavior has changed can provide insight, but it does not ensure the safety of the client.
Choice D rationale:
Monitoring the client’s whereabouts at all times is important as a sudden change in mood can indicate a higher risk of suicide.
Correct Answer is D
Explanation
Choice A rationale:
While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.
Choice B rationale:
Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.
Choice C rationale:
Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.
Choice D rationale:
Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.
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