Nokea
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)
- A. Impulsive behaviors
- B. Sleeping for long periods of time
- C. Interacting with others in a flirtatious way
- D. Dressing in black or grey clothing
- E. Talking in rapid,continuous speech
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. Impulsive behaviors, interacting flirtatiously, and talking rapidly are classic manifestations of manic behavior in bipolar disorder. Impulsive actions can lead to risky behaviors. Flirtatious interactions are often inappropriate and lack boundaries. Rapid, continuous speech is a hallmark of mania, reflecting racing thoughts and pressured speech. Choices B and D do not align with manic behavior. Sleeping for long periods is more indicative of depression, while dressing in black or grey clothing does not directly correlate with manic episodes.
You may also like to solve these questions
A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?
- A. Enoxaparin
- B. Alteplase (tPA)
- C. Warfarin
- D. Clopidogrel
Correct Answer: A
Rationale: The correct answer is A: Enoxaparin. Enoxaparin is a low molecular weight heparin that helps prevent deep vein thrombosis (DVT) by inhibiting clot formation. It is commonly prescribed postoperatively for clients undergoing knee replacement surgery due to the increased risk of DVT. Alteplase (tPA) is a thrombolytic agent used to dissolve existing blood clots and not typically used for prevention. Warfarin is an oral anticoagulant that requires monitoring of INR levels and is usually started after initial treatment with heparin. Clopidogrel is an antiplatelet agent and is not typically used for DVT prevention.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
Which of the following factors may contribute to an increased risk of suicide?
- A. Engaging in regular physical exercise
- B. Having a positive self-esteem
- C. Having a strong social support system
- D. Experiencing a history of trauma or abuse
Correct Answer: D
Rationale: The correct answer is D: Experiencing a history of trauma or abuse. Research shows that individuals who have experienced trauma or abuse are at a higher risk of suicide due to the psychological impact of such experiences. Trauma can lead to feelings of hopelessness, worthlessness, and despair, increasing suicidal ideation. Now, let's analyze why the other choices are incorrect. A: Engaging in regular physical exercise can actually reduce the risk of suicide by improving mental health and overall well-being. B: Having a positive self-esteem is also a protective factor against suicide as it fosters resilience and coping skills. C: Having a strong social support system is crucial in preventing suicide, as it provides emotional support and a sense of belonging, therefore decreasing the risk.
A school nurse is speaking to the mother of a 16-year-old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide?
- A. He is very religious and attends services twice a week.
- B. His cousin committed suicide a few weeks ago.
- C. He has slept 9 hours each night for the past 2 years.
- D. He spends much of his time with his two school friends.
Correct Answer: B
Rationale: The correct answer is B because a significant risk factor for suicide is having a close family member who has died by suicide. It indicates a potential increased vulnerability due to exposure to suicide and the impact of grief. Choice A (religious) and D (socially connected) are protective factors that can reduce suicide risk. Choice C (consistent sleep) is not directly related to suicide risk.
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.