A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

Short, polite responses to interview questions

Introspection related to present situation

Feelings of helplessness and hopelessness

Disorganized thinking and the inability to remain seated.

Answer and Explanation

The Correct Answer is D

D. Mania is characterized by symptoms such as increased energy levels, decreased need for sleep, impulsivity, racing thoughts, and agitation. Disorganized thinking, rapid speech, and an inability to remain seated are common manifestations of manic symptoms.
A. Clients in a manic episode often exhibit rapid speech, tangential thinking, and may be overly talkative rather than providing short, polite responses.
B. Manic individuals typically exhibit heightened energy levels, impulsivity, and distractibility, making it challenging for them to engage in introspection or focus on the present situation. Instead, they may be preoccupied with grandiose ideas, racing thoughts, or engaging in excessive activities.
C. This response is more characteristic of individuals experiencing depressive episodes of bipolar disorder rather than manic episodes. During a depressive episode, individuals with bipolar disorder may experience profound feelings of sadness, hopelessness, and helplessness, along with symptoms such as fatigue, changes in appetite or weight, and sleep disturbances.

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Correct Answer is C

Explanation

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

A. "I'm too ashamed to talk about it." B. "I'm really sorry about all the people I've hurt." C. "I just don't remember doing it." D. "It's not my fault."

Correct Answer is D

Explanation

D. This response is consistent with the characteristics of antisocial personality disorder, which include a lack of remorse, as well as a tendency to rationalize behavior or blame others. Individuals with this disorder often fail to accept responsibility for their actions and may exhibit behaviors that are impulsive, reckless, and violate the rights of others without feeling guilty.
A. Individuals with antisocial personality disorder often lack remorse or empathy for the consequences of their actions and may not experience feelings of shame or guilt, even when their behavior results in harm to others.
B. Expressing genuine remorse or empathy for the harm caused to others is uncommon in individuals with antisocial personality disorder.
C. Claiming to have no memory of the behavior or the events leading up to it is a common defense mechanism used. This may serve to avoid accountability or responsibility for their actions, rather than indicating genuine memory impairment. However, it is not characteristic for antisocial personality disorder.

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A family describes a client diagnosed with bipolar disorder as being "on the move." The client sleeps 3-4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which response would the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?

Correct Answer is D

Explanation

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