A nurse is collecting data from a client who has bipolar disorder with mania.
Which finding is the nurse’s priority?

The client gives personal items and money away to other clients.

The client is hostile and sarcastic towards the staff.

The client paces in the hallway during the day and most of the night.

The client demonstrates flight of ideas.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. The client paces in the hallway during the day and most of the night.

Choice A rationale: Giving away personal items and money can indicate impulsivity and poor judgment, which are common in manic episodes. However, this behavior does not pose an immediate physical risk to the client or others.

Choice B rationale: Hostility and sarcasm towards staff can indicate irritability and agitation, which are also common in mania. While this behavior can disrupt the therapeutic environment, it is not the highest priority unless it escalates to physical aggression.

Choice C rationale: Pacing in the hallway during the day and most of the night indicates severe hyperactivity and potential exhaustion. This behavior poses a significant risk to the client’s physical health due to the possibility of dehydration, exhaustion, and other complications from lack of rest.

Choice D rationale: Demonstrating flight of ideas is a cognitive symptom of mania where the client rapidly shifts from one idea to another. While this can affect communication and thought processes, it does not pose an immediate physical risk.

In summary, the priority is to address behaviors that pose the greatest immediate risk to the client’s physical health and safety.

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Correct Answer is D

Explanation

Choice A rationale:

Increased salivation is a common side effect of haloperidol, but it is not the most serious adverse effect that the nurse should monitor for. It can be managed with medications such as anticholinergics, and it often subsides with continued use of haloperidol. Choice B rationale:

Serotonin syndrome is a rare but potentially life-threatening condition that can occur when haloperidol is combined with other medications that increase serotonin levels, such as antidepressants. However, it is not a direct adverse effect of haloperidol itself.

Choice C rationale:

Increased menstrual bleeding is not a known side effect of haloperidol.

Choice D rationale:

Tardive dyskinesia is a serious and potentially irreversible movement disorder that can occur as a long-term side effect of haloperidol and other antipsychotic medications. It is characterized by involuntary, repetitive movements of the face, tongue, and limbs.

The risk of tardive dyskinesia increases with the length of time that a person takes haloperidol and with the dose of the medication.

There is no cure for tardive dyskinesia, but the symptoms can sometimes be managed with medications.

It is important for nurses to monitor patients who are taking haloperidol for signs of tardive dyskinesia, so that the medication can be discontinued if necessary.

A. Establish rapport with the client. B. Avoid making eye contact when addressing the client. C. Speak to the client using a high-pitched voice. D. Validate the client’s feelings and identify the cause of the anxiety.

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

Explanation

The correct answer is choice A and D.

Choice A rationale:

Establishing rapport with the client is a fundamental nursing action to create a trusting relationship, which is especially important when a client is experiencing acute anxiety. A strong rapport can help the client feel more secure and supported, making it easier to manage their anxiety.

Choice B rationale:

Making eye contact is generally considered a non-threatening and effective way to communicate care and attention. Avoiding eye contact could make the client feel isolated or ignored. Therefore, this is not a recommended action when attending to a client with acute anxiety.

Choice C rationale:

Using a high-pitched voice can be perceived as alarming or stressful, which may exacerbate the client’s anxiety. It is important to use a calm, soothing tone when speaking to someone who is anxious.

Choice D rationale:

Validating the client’s feelings and identifying the cause of the anxiety are therapeutic techniques that acknowledge the client’s experience and can help in addressing the underlying issues contributing to the anxiety. This can be a crucial step in helping the client to cope with and overcome their anxiety.

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A nurse is collecting data from a client who has bipolar disorder with mania. Which finding is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is D

Explanation

A nurse is attending to a client experiencing acute anxiety. Which of the following actions should the nurse undertake? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client demonstrates concrete thinking?

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A nurse is caring for a client who has borderline personality disorder (BPD). What should the nurse monitor in the client’s Medication Administration Record?

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A nurse is collecting data from a client who has bipolar disorder with mania.
Which finding is the nurse’s priority?