A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?

Grandiose thinking

Hypersomnia

Blunted affect

Slurred speech

Answer and Explanation

The Correct Answer is A

Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.

Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.

Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.

Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.

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Correct Answer is B

Explanation

The nurse should identify that disposing of contaminated sheets in a linen bag demonstrates effective use of supplies.

Wearing an N95 mask when bathing a client with Clostridium difficile is important, but it is not related to effective use of supplies.

Wearing clean gloves when performing oral hygiene is standard practice for infection control and not specific to the use of supplies.

Empting the sharps container when it is full is also important, but it is not related to effective use of supplies.

A. Temperature 38.8° C (101.8° F) B. Straw-colored urine C. Apical pulse rate 58/min D. Blood pressure 158/92 mm Hg

Correct Answer is A

Explanation

The correct answer is: a. Temperature 38.8° C (101.8° F)

Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.

Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.

Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.

Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.

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A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

Correct Answer is B

Explanation

A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?

Correct Answer is A

Explanation

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