A nurse is caring for a client in a manic state of her Bipolar disorder. The client is dancing around the dayroom of the inpatient lounge. When she twirled her skirt it was obvious she was not wearing any underwear. The nurse enters the area and distracts her. She takes her to her room to put on underwear. Why did the nurse take this action?
To avoid her embarrassing herself in her manic state/behavior
Because there is no dancing allowed in the day room with other clients
To avoid her sexual passes at the clients
Because she was not following policy
The Correct Answer is A
A. The nurse’s primary concern is preventing the client from embarrassing herself due to the impulsive and disinhibited behaviors typical of a manic episode.
B. There is no indication that dancing is prohibited; the issue is with inappropriate behavior.
C. The focus of the action is not on sexual behavior but on ensuring the client is appropriately dressed in a social setting.
D. Following policy is important, but the nurse’s action is more about protecting the client from social
embarrassment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change.
B. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another.
C. While this is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range.
D. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min). Therefore, notifying the doctor of bradycardia is not appropriate in this case.
Correct Answer is A
Explanation
A. Disorganized speech is a symptom of acute mania, where the client may speak rapidly and jump from one topic to another.
B. Auditory hallucinations (hearing voices) are not typical of acute mania; they are more commonly associated with psychosis or schizophrenia.
C. Dressing in all black is not indicative of acute mania and could be a sign of depression.
D. Weight gain is not a symptom of acute mania. Instead, it may be related to other factors such as medications or depression.
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