A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?
The client responds to questions with disorganized speech.
The client reports that voices are telling him to write a novel.
The client's spouse reports that the client has recently gained weight.
The client is dressed in all black.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: Disorganized speech is a hallmark symptom of acute mania in bipolar disorder. Clients may exhibit pressured speech, tangentiality, and flight of ideas, reflecting the heightened energy and cognitive disruptions associated with manic episodes.
Choice B rationale: Reporting auditory hallucinations, such as voices telling the client to write a novel, is more indicative of a psychotic disorder rather than acute mania in bipolar disorder. Mania typically involves elevated mood and activity levels, not hallucinations.
Choice C rationale: Weight gain reported by the spouse is not specific to acute mania. While changes in appetite and weight can occur in bipolar disorder, they are not defining features of manic episodes, which are characterized by heightened mood and activity.
Choice D rationale: Being dressed in all black does not specifically indicate acute mania. Mania is characterized by mood disturbances and increased activity levels rather than specific choices in clothing color, which can vary widely among individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: Continuous worry about the undiagnosed presence of an illness.
Choice A rationale:
Sudden unexplained loss of peripheral sensation is not typically associated with illness anxiety disorder. This symptom may be indicative of a neurological condition and would require further medical evaluation to determine the cause.
Choice B rationale:
Obsession over a fictitious defect in physical appearance is more characteristic of body dysmorphic disorder, not illness anxiety disorder. Individuals with body dysmorphic disorder are preoccupied with one or more perceived defects or flaws in their physical appearance, which are not observable or appear slight to others.
Choice C rationale:
Having prior physical health followed by the need for two surgeries within the last three months does not necessarily indicate illness anxiety disorder. This choice does not provide enough context to link it to illness anxiety disorder, as it could be related to many other health conditions.
Choice D rationale:
Continuous worry about the undiagnosed presence of an illness is a key finding in illness anxiety disorder. Individuals with this disorder are excessively concerned with and preoccupied by the belief that they have, or are in danger of developing, a serious undiagnosed illness despite medical reassurance.
Correct Answer is D
Explanation
Choice A rationale:
Establishing trust with a caregiver in just five days is a challenging and unrealistic expectation for a child diagnosed with autistic spectrum disorder (ASD). Building trust takes time, especially for individuals with ASD who may struggle with social interactions and forming connections.
Choice B rationale:
Participating in a team sport with peers by day 4 might be too ambitious for a child with ASD. Children with ASD often require gradual exposure and support to engage in social activities, and such rapid participation might lead to anxiety and discomfort.
Choice C rationale:
While communication goals are important for children with ASD, expecting them to communicate all needs verbally by discharge might not be realistic. Many children with ASD use alternative forms of communication, such as gestures or assistive devices, which should also be considered as valid modes of expression.
Choice D rationale:
The realistic outcome for a child diagnosed with ASD is that they will perform most self-care tasks independently. ASD often affects social and communication skills, but children can learn and develop the ability to manage self-care tasks with proper support and intervention. This outcome aligns with the developmental trajectory of children with ASD.
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