A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? Select all that apply.

Talking in rapid, continuous speech.

Interacting with others in a flirtatious way.

Dressing in black or grey clothing.

Sleeping for long periods of time.

Spending large sums of money.

Answer and Explanation

Correct Answer : A,B,E

Choice A reason: Rapid, continuous speech is a common symptom of manic behavior, as individuals may feel an increased pressure to speak.

Choice B reason: Flirtatious interaction can be part of the increased sociability and decreased inhibition associated with mania.

Choice C reason: Dressing in black or grey clothing is not specifically indicative of manic behavior.

Choice D reason: Sleeping for long periods is more commonly associated with depressive episodes, not manic behavior.

Choice E reason: Spending large sums of money recklessly can be a sign of the impulsivity and poor judgment that accompany manic episodes.

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Correct Answer is B

Explanation

Choice A reason: Focusing on one issue can help in understanding the client's situation better and does not necessarily hinder empathy.

Choice B reason: Interjecting personal experiences can create a barrier to empathy by shifting the focus from the client's feelings to the nurse's own experiences.

Choice C reason: Asking leading questions may not hinder empathy but could direct the conversation away from the client's concerns.

Choice D reason: Asking the client to restate statements for clarity is a part of active listening and can actually enhance empathy by ensuring understanding.

A. Check the client's pupil reactivity. B. Perform a developmental screening test. C. Prepare the client for a CT scan. D. Obtain a urine specimen. E. Monitor the client’s vital signs frequently.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Checking the client's pupil reactivity is important because alcohol intoxication can affect the nervous system, which may be reflected in changes in pupil size and reactivity to light. Normal pupil size ranges from about 2 to 4 mm in diameter in bright light to 4 to 8 mm in the dark. Pupils that do not respond to light could indicate a neurological deficit that requires immediate attention.

Choice B Reason:

Performing a developmental screening test is not typically indicated for acute alcohol intoxication management. Developmental screenings are generally used to assess children for appropriate growth and developmental milestones, not for adults in an emergency setting due to intoxication.

Choice C Reason:

Preparing the client for a CT scan may be necessary if there is a suspicion of head trauma or intracranial bleeding, which can occur with falls or injuries associated with intoxication. A CT scan can help identify any urgent issues that need to be addressed.

Choice D Reason:

Obtaining a urine specimen can be useful for several reasons. It can be tested for the presence of alcohol, other substances, or toxins. Additionally, it can provide information about the client's overall health and kidney function.

Choice E Reason:

Monitoring the client’s vital signs frequently is crucial. Alcohol intoxication can lead to vital sign abnormalities such as hypotension, tachycardia, or respiratory depression. Normal ranges for vital signs vary but generally include a blood pressure of 90/60 mmHg to 120/80 mmHg, a heart rate of 60 to 100 beats per minute, and a respiratory rate of 12 to 20 breaths per minute.

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A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is attempting to develop empathy for a client but is not completely feeling empathetic. Which factor might be hindering the nurse from developing empathy for this client?

Correct Answer is B

Explanation

A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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