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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:
Command hallucinations can direct the patient to harm themselves or others, making it the priority to address.
Choice B rationale:
Tactile hallucinations, while distressing, are not typically as immediately dangerous as command hallucinations.
Choice C rationale:
Gustatory hallucinations, while potentially disturbing, do not usually pose an immediate threat.
Choice D rationale:
Visual hallucinations, while potentially distressing, are not typically as immediately dangerous as command hallucinations.

A. "I know you hear the voices, but I do not.”. B. "The voices are part of your illness.”. C. "How often do you hear the voices?". D. "What are the voices telling you?".

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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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?