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A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania.
Which of the following findings should the nurse expect? (Select all that apply.).

Anhedonia.

Distractibility.

Grandiose thinking.

Overeating.

Flight of ideas.

Answer and Explanation

Correct Answer : B,C,E

Correct Answers: Distractibility. Grandiose thinking. Flight of ideas.

These are the common symptoms of mania in bipolar disorder.

Some possible explanations for the other choices are:

Choice A is wrong because anhedonia, which means loss of interest or pleasure in activities, is a symptom of depression, not mania.
Choice D is wrong because overeating is not a specific symptom of mania, although some people with bipolar disorder may have changes in appetite or weight during mood episodes.

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Correct Answer is C

Explanation

This can be a sign of preeclampsia, a serious complication of pregnancy that causes high blood pressure and proteinuria.

The nurse should report this finding to the provider and monitor the client’s blood pressure, urine protein, and reflexes.

Choice A is wrong because leg cramps are a common discomfort during pregnancy and are not usually a sign of a complication.

Choice B is wrong because ptyalism, or excessive salivation, is a normal physiological change during pregnancy and does not indicate a problem.

Choice D is wrong because melasma, or darkening of the skin on the face, is also a normal physiological change during pregnancy and does not pose a risk to the mother or the fetus.

A. The nurse checks the volume of the aspirate. B. The nurse checks the pH of the aspirate. C. The nurse administers 15 mL of water before administering the feeding. D. The nurse adds food coloring to the tube feeding.

Correct Answer is D

Explanation

This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.

Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.

Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.

Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.

Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.

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A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania.
Which of the following findings should the nurse expect? (Select all that apply.).