A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which of the following findings should the nurse expect?
Client reports auditory hallucinations.
Client expresses illusions of grandeur.
Moves quickly from one idea to the next.
Inability to carry out a simple task.
The Correct Answer is D
Choice A rationale:
Auditory hallucinations are more commonly associated with conditions like schizophrenia or certain types of psychosis. In bipolar disorder, individuals may experience mood swings between depression and mania, but auditory hallucinations are not a typical symptom during a depressive episode.
Choice B rationale:
Illusions of grandeur involve an exaggerated sense of one's importance, power, knowledge, or identity. This symptom is more commonly associated with manic episodes in bipolar disorder, not depressive episodes.
Choice C rationale:
Rapid speech and moving quickly from one idea to the next are characteristic symptoms of a manic episode in bipolar disorder, not a depressive episode. During depressive episodes, individuals often exhibit symptoms such as low energy, feelings of worthlessness, and difficulty concentrating.
Choice D rationale:
Inability to carry out a simple task is a common symptom of depression. Depressed individuals often struggle with daily activities, lose interest in hobbies, and have difficulty concentrating. This symptom aligns with the depressive episode of bipolar disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Uses a firm-bristled toothbrush increases the client's risk for injury because it can cause bleeding gums and oral mucosal damage in clients with pernicious anemia, who have reduced platelet count and impaired clotting. The other findings do not increase the risk for injury and may be beneficial for clients with pernicious anemia. Increased intake of green, leafy vegetables provides folic acid, which is essential for red blood cell production. Drinks 2,500 mL of fluid per day prevents dehydration and maintains blood volume. Wears a face mask around others reduces exposure to infections, which can be serious in clients with pernicious anemia, who have impaired immunity due to low white blood cell count.
Correct Answer is A
Explanation
The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.
Choice A rationale:
Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.
Choice B rationale:
While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.
Choice C rationale:
Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.
Choice D rationale:
Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.
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