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.
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Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort
Explanation:
St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.
In the given scenario, the nurse should identify:
Condition: The client's intake of St. John's wort
Client Finding: At risk for developing serotonin syndrome
This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.
Correct Answer is D
Explanation
A. Exploring reasons for her behavior is important for understanding the underlying issues, but the immediate priority is to ensure the client's safety.
B. Providing strategies for redirecting violent behavior is a relevant intervention, but it is not the priority in this situation. Safety concerns related to self-harm take precedence.
C. Encouraging the client to talk about her feelings is a valuable therapeutic intervention, but in the context of borderline personality disorder, the immediate priority is to address the risk of self-harm. Once the client's safety is ensured, exploring feelings and developing coping strategies can be part of the ongoing therapeutic process.
D. Protecting the client from self-harm behavior is the priority because individuals with borderline personality disorder are at an increased risk of engaging in self-harming behaviors,
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