A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

Writes a detailed daily activity schedule

Isolates self from others

Reports a lack of sleep

Refuses to engage in conversation

Answer and Explanation

The Correct Answer is C

A.   Writing a detailed daily activity schedule may indicate organization and planning, which are not typically associated with acute mania.
B.   Isolating oneself from others could be a sign of depression rather than acute mania.
C.   Reporting a lack of sleep is characteristic of acute mania, as individuals in manic episodes often experience decreased need for sleep.
D.   Refusing to engage in conversation could be indicative of various factors, but it is not specific to acute mania.

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Correct Answer is A

Explanation

A. Displacement involves redirecting emotions or behaviors from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting his anger from his partner to the nurse, who is perceived as a safer target.
B. Compensation involves overachieving in one area to compensate for deficiencies in another area and is not demonstrated in this scenario.
C. Denial involves refusing to acknowledge the existence of a real situation or the feelings associated with it, which is not evident in the client's behavior.
D. Rationalization involves creating logical or socially acceptable explanations for behaviors or feelings that are unacceptable, which is not demonstrated in the client's behavior in this scenario.

A. Oxygen saturation B. Blood pressure C. Bowel sounds D. Pupil response

Correct Answer is B

Explanation

A. Oxygen saturation is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
B. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Therefore, assessing the client's blood pressure is essential to monitor for potential hypertensive effects.
C. Bowel sounds are not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
D. Pupil response is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.

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A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is A

Explanation

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

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