A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

Speaks in rhyming sentences

Makes inappropriate sexual comments

States that he hasn't bathed in 2 days

Reports eating twice in the past week

Answer and Explanation

The Correct Answer is D

A.   Speaking in rhyming sentences can be a manifestation of mania but may not necessarily require immediate reporting unless it escalates to disruptive or harmful behavior.
B.   Making inappropriate sexual comments can indicate impulsivity and lack of social boundaries. It does not however precede managing the risk of hypoglycemia.
C.   Poor hygiene, such as not bathing, is common in mania due to increased energy and decreased need for sleep, but it may not require immediate reporting unless it poses a significant risk to the client's health.
D.   Decreased appetite and irregular eating patterns are common during mania due to increased activity levels. Eating twice in teh past is not sufficient to meet energy requirements and the client might be at risk of hypoglycemia.

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Correct Answer is B

Explanation

A. While a client with anorexia nervosa may require close monitoring and support, expressing a fear of gaining weight does not necessarily indicate an immediate safety concern that requires an update to the plan of care.

B. Bipolar disorder can involve manic episodes characterized by impulsivity and risk-taking behaviors. Exhibiting poor impulse control indicates a potential safety concern that requires an update to the plan of care to ensure the client's safety and the safety of others.
C. Clang associations in speech are a symptom of disorganized thinking commonly seen in schizophrenia. While it may indicate a need for intervention, it does not necessarily require an immediate update to the plan of care for safety reasons.
D. Difficulty remembering names of family members is a symptom of Alzheimer's disease and may require ongoing support and management but does not present an immediate safety concern that requires an update to the plan of care.

A. Document the client's behavior every 15 min. B. Obtain the provider's prescription within 60 min. C. Monitor the client's vital signs every 4 hr. D. Offer the client food and fluids every 2 hr.

Correct Answer is A

Explanation

A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.

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A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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