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

- Choice A Rationale: This statement does not indicate spiritual distress. On the contrary, it suggests that the client's faith is a source of strength and hope, which is typically a sign of positive spiritual well-being.
- Choice B Rationale:

This statement suggests a disruption in the client's spiritual practices, which could lead to spiritual distress as it interferes with a meaningful coping mechanism.

- Choice C Rationale: Similar to choice A, this statement reflects a positive aspect of the client's spirituality. Finding comfort in meditation is indicative of a beneficial spiritual practice and does not suggest distress.
- Choice D Rationale:

This reflects active spiritual support, which is helpful during illness and not indicative of spiritual distress.

A. Place the client in a reclining chair. B. Put locks at top of doors. C. Encourage physical activity prior to bed time. D. Position the mattress on the floor. E. Install sensor devices on outside doors.

Correct Answer is ["B","C","D","E"]

Explanation

A. Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B. Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C. Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D. Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E. Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["B","C","D","E"]

Explanation

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