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
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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Related Questions
Correct Answer is C
Explanation
A. Coercing the client into treatment violates the client's autonomy and rights. Involuntary commitment does not mean the client loses the right to refuse treatment.
B. Involving the client's family without their consent or participation in decision-making may not be appropriate and could breach confidentiality.
C. Documenting the client's refusal of treatment ensures that the decision is appropriately recorded in the medical record and facilitates communication among the healthcare team members. It also protects the client's autonomy and legal rights.
D. Informing the client that ECT does not require consent is incorrect. While laws regarding involuntary treatment vary by jurisdiction, clients generally have the right to refuse treatment, even if they are involuntarily committed.
Correct Answer is C
Explanation
A. Soy protein is not known to interact adversely with fluoxetine.
B. Echinacea is not known to interact adversely with fluoxetine.
C. St. John's wort is known to interact adversely with fluoxetine by increasing serotonin levels, which can lead to serotonin syndrome, a potentially life-threatening condition characterized by symptoms such as confusion, agitation, rapid heart rate, and high blood pressure.
D. Ginkgo biloba is not known to interact adversely with fluoxetine.
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