A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

Writes a detailed daily activity schedule

Isolates self from others

Reports a lack of sleep

Refuses to engage in conversation

Answer and Explanation

The Correct Answer is C

A.   Writing a detailed daily activity schedule may indicate organization and planning, which are not typically associated with acute mania.
B.   Isolating oneself from others could be a sign of depression rather than acute mania.
C.   Reporting a lack of sleep is characteristic of acute mania, as individuals in manic episodes often experience decreased need for sleep.
D.   Refusing to engage in conversation could be indicative of various factors, but it is not specific to acute mania.

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Correct Answer is D

Explanation

A. Explaining implied consent to the client's family does not address the need for obtaining informed consent for a legally incompetent client.
B. Asking the charge nurse to obtain informed consent may not be appropriate, as the responsibility for obtaining consent typically falls on the healthcare provider or a designated individual.
C. While the social worker may be involved in the process of obtaining consent for a legally incompetent client, it is not their sole responsibility, and the nurse should be actively involved in the process.
D. When a client has been declared legally incompetent, consent must be obtained from the client's legally appointed guardian or surrogate decision-maker.

A. "Ask a family member to check the locks for you at night." B. "Keep a journal of how often you check the locks each night." C. "Focus on abdominal breathing whenever you go to check the locks." D. "Snap a rubber band on your wrist when you think about checking the locks."

Correct Answer is D

Explanation

A. Asking a family member to check the locks for the client may alleviate immediate anxiety but does not address the underlying obsessive-compulsive behavior or provide coping mechanisms for the client to manage their symptoms independently.
B. Keeping a journal of checking behaviors may be part of exposure and response prevention therapy but does not directly address the intrusive thoughts associated with obsessive- compulsive disorder in the moment.
C. Focusing on abdominal breathing is a relaxation technique that may help reduce overall anxiety but does not specifically target the intrusive thoughts associated with obsessive- compulsive disorder.
D. Using a rubber band to snap on the wrist when the client thinks about checking the locks is a form of aversion therapy, which is a component of thought stopping technique. This technique helps interrupt and redirect the obsessive thoughts, promoting awareness and control over compulsive behaviors.

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A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

Correct Answer is D

Explanation

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