A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)
Exhibiting clang associations
interacting with others in a flirtatious way
Reports sleeping for long periods of time
Talking in rapid continuous speech
Reports spending large sums of money
Correct Answer : A,B,D,E
A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.
B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.
C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.
D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.
E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
The "3" findings that should indicate to the nurse that the client is experiencing negative symptoms related to their schizophrenia are:
B.Lack of motivation
D.Lack of energy
E.Withdrawn
Explanation:
Negative symptoms in schizophrenia involve deficits or reductions in normal emotional and behavioral functioning. In the provided nurse's notes:
Blood pressure: Blood pressure is not mentioned in the nurse's notes, and it is not directly indicative of negative symptoms in schizophrenia.
B. Lack of motivation: The client refusing to eat or drink, not engaging in conversation, and not wanting to go to therapy sessions are indicative of a lack of motivation, which is a negative symptom.
C. Change in behavior: While there is a change in behavior mentioned in the notes (refusing to eat or drink, not engaging in conversation), the specific behavioral changes described are more closely associated with negative symptoms. Negative symptoms involve a reduction or loss of normal functions.
D. Lack of energy: The client's slow movements and desire to sleep suggest a lack of energy, another negative symptom associated with schizophrenia.
E. Withdrawn: The client's withdrawal from social interaction, as evidenced by not engaging in conversation and wanting to sleep, is characteristic of withdrawal, which is a negative symptom.
Correct Answer is ["A","D","E","F","G"]
Explanation
A. Sodium level:
Abnormal sodium levels can have serious consequences, including neurological symptoms. Immediate follow-up is necessary to assess and manage electrolyte imbalances, as severe cases can lead to complications such as seizures.
B. Phosphate level:
While phosphate levels are important to monitor, they may not require immediate follow-up unless severe abnormalities are present. Severe phosphate imbalances can occur in the context of malnutrition, but they may not necessitate immediate intervention in the ED unless critical.
C. Magnesium level:
Similar to phosphate, magnesium levels are crucial but may not demand immediate follow-up unless severe abnormalities are detected. While magnesium imbalances can occur in eating disorders, the urgency depends on the extent of the imbalance.
D. Respiratory rate:
Rapid or abnormal respiratory rates can be indicative of respiratory distress, which may occur in individuals with severe anorexia nervosa. Monitoring and addressing respiratory issues promptly are crucial for the client's respiratory function.
E. Capillary refill:
Capillary refill is included in the list of findings that require immediate follow-up. Prolonged capillary refill time indicates potential issues with peripheral perfusion and warrants prompt attention to assess and address any circulation concerns.
F. Blood pressure:
Abnormal blood pressure, especially low blood pressure, can indicate cardiovascular compromise, which is a concern in severe cases of anorexia nervosa. Monitoring and addressing abnormal blood pressure promptly are essential for the client's well-being.
G. Glucose level:
Anorexia nervosa can lead to hypoglycemia, and low glucose levels can result in various complications, including neurological symptoms. Immediate follow-up is necessary to assess and manage glucose levels for the well-being of the client
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