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 B
Explanation
A. Bipolar type is not a specific classification; the nurse needs to differentiate between bipolar I and II.
B. Bipolar type I involves manic episodes that last for at least a week or require hospitalization, with possible depressive episodes. The presence of a depressive episode confirms bipolar type I.
C. Bipolar mixed refers to simultaneous symptoms of both mania and depression, which is not described here.
D. Anxiety is unrelated to the symptoms described.
Correct Answer is C
Explanation
A. Asking why the client doesn't see the value of treatment is confrontational and dismisses the client’s
experience.
B. Suggesting a group home without addressing the client’s personal goals or preferences could be perceived as dismissive.
C. While complete symptom resolution is not guaranteed, focusing on improving the client’s quality of
life and continuing treatment is more realistic and supportive.
D. The medical model of recovery emphasizes symptom management, but suggesting it works to eliminate all symptoms may be overly optimistic for someone with schizophrenia.
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