A nurse is collecting data from a client who has bipolar disorder. The nurse should identify that which of the following findings places the client at an increased risk for injury due to mania?
The client spends most of their day sleeping.
The client is easily distracted by external stimuli.
The client withdraws from group activities.
The client will only eat finger foods.
The Correct Answer is B
A. The client spends most of their day sleeping: Excessive sleep is more characteristic of depressive episodes in bipolar disorder. While fatigue can contribute to risk in some contexts, it does not directly indicate increased injury risk from manic behaviors.
B. The client is easily distracted by external stimuli: Distractibility is a hallmark of mania and can lead to impulsive or unsafe actions, such as leaving dangerous objects within reach, wandering, or starting multiple activities at once. This significantly increases the client’s risk for injury.
C. The client withdraws from group activities: Social withdrawal is more associated with depressive states. While it may affect engagement or mood, it does not inherently increase risk for injury due to manic behavior.
D. The client will only eat finger foods: Preferring finger foods may indicate impulsivity or hyperactivity but does not directly correlate with a substantial risk for injury. Safety risks are more closely tied to distractibility, poor judgment, and impulsive actions during mania.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The toddler can remove her own socks: This demonstrates fine motor development and self-help skills typical for an 18-month-old. Activities such as removing clothing or manipulating objects indicate appropriate progression of autonomy and dexterity.
B. The toddler has a security blanket: Attachment to a security object is a normal behavior that provides comfort and emotional regulation. It is developmentally appropriate for toddlers and does not indicate a developmental delay or health concern that requires provider notification.
C. The toddler can say four words: By 18 months, toddlers are expected to have a vocabulary of approximately 10–20 words and begin combining words into simple phrases. A vocabulary limited to four words may indicate delayed speech and language development, warranting further evaluation by the provider or referral to a speech-language pathologist.
D. The toddler throws a ball without falling: Gross motor skills such as throwing a ball, walking, and climbing stairs independently are appropriate for an 18-month-old. This finding demonstrates normal motor development and coordination and does not require reporting.
Correct Answer is C
Explanation
A. Apply sterile gloves after performing hand hygiene: Applying a condom catheter does not require sterile technique. Clean gloves are appropriate to reduce the risk of infection, but sterile gloves are unnecessary, as the procedure is considered noninvasive and low risk for introducing pathogens.
B. Unroll the catheter before applying it to the penis: The condom catheter should be unrolled onto the penis during application, not before, to ensure proper fit and prevent twisting or air pockets. Pre-unrolling can make placement difficult and may compromise the seal, increasing the risk of leakage.
C. Leave space between the tip of the penis and the end of the condom catheter: Leaving a small space (about 1–2 cm) at the tip prevents pressure on the glans, reduces the risk of irritation or ischemia, and allows urine to flow freely into the collection bag without causing trauma to the penis. This is a key aspect of safe and effective application.
D. Tape the condom catheter to the penis using waterproof adhesive tape: The catheter should not be secured with adhesive tape around the shaft, as this can cause constriction, skin breakdown, or impaired circulation. Most condom catheters have self-adhesive or elastic sheaths that secure the device without additional taping.
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