A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which of the following findings should the nurse expect?
Client reports auditory hallucinations.
Client expresses illusions of grandeur.
Moves quickly from one idea to the next.
Inability to carry out a simple task.
The Correct Answer is D
Choice A rationale:
Auditory hallucinations are more commonly associated with conditions like schizophrenia or certain types of psychosis. In bipolar disorder, individuals may experience mood swings between depression and mania, but auditory hallucinations are not a typical symptom during a depressive episode.
Choice B rationale:
Illusions of grandeur involve an exaggerated sense of one's importance, power, knowledge, or identity. This symptom is more commonly associated with manic episodes in bipolar disorder, not depressive episodes.
Choice C rationale:
Rapid speech and moving quickly from one idea to the next are characteristic symptoms of a manic episode in bipolar disorder, not a depressive episode. During depressive episodes, individuals often exhibit symptoms such as low energy, feelings of worthlessness, and difficulty concentrating.
Choice D rationale:
Inability to carry out a simple task is a common symptom of depression. Depressed individuals often struggle with daily activities, lose interest in hobbies, and have difficulty concentrating. This symptom aligns with the depressive episode of bipolar disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.
Correct Answer is A
Explanation
The correct answer is Choice a.
Choice a rationale: The nurse should obtain the specimen immediately upon the client waking up, as sputum from deep in the lungs is usually more easily collected at this time. Sputum collected upon waking up is more likely to contain secretions from the lower respiratory tract, providing a better sample for tuberculosis diagnosis. This timing maximizes the chance of detecting the bacteria.
Choice b rationale: Choice b is incorrect because the typical volume of sputum needed for testing is about 1 teaspoon (5 mL), not 15 to 20 mL. Collecting such a large volume could be challenging for the client and unnecessary for diagnostic purposes.
Choice c rationale: Choice c is incorrect because while gloves should be worn, they do not need to be sterile, just clean. The use of clean gloves is sufficient to prevent contamination during specimen collection, and sterile gloves are not required for this procedure.
Choice d rationale: Choice d is incorrect because it’s important to try to collect the specimen as soon as possible, not wait a full day. Delaying collection for a day could result in a missed opportunity to diagnose tuberculosis and initiate appropriate treatment promptly. Collecting the specimen promptly maximizes the accuracy of diagnostic testing and facilitates timely intervention for the client's health.
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