A nurse is collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect?

Flight of ideas

Ritualistic behaviour

Well-groomed appearance

Command hallucinations

Answer and Explanation

The Correct Answer is A

A. Flight of ideas: Flight of ideas is a classic finding in clients experiencing a manic episode of bipolar disorder. It is characterized by rapid, continuous shifts from one topic to another, often making it difficult for the listener to follow the conversation. This reflects the elevated mood and pressured speech typical of mania.

B. Ritualistic behavior: Ritualistic behaviors, such as repetitive actions or strict routines, are more commonly associated with obsessive-compulsive disorder (OCD) rather than bipolar disorder. While clients with bipolar disorder may show disorganized behavior during mania, ritualism is not a hallmark feature.

C. Well-groomed appearance: During manic or depressive episodes of bipolar disorder, clients often experience a decline in self-care and grooming. A consistently well-groomed appearance would be more typical of a stable, euthymic phase rather than during an active mood episode.

D. Command hallucinations: Command hallucinations are typically linked to psychotic disorders such as schizophrenia. Although severe mania can include psychotic features, hallucinations are not a primary or consistent symptom in bipolar disorder unless it becomes a psychotic manic or depressive episode.

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Correct Answer is C

Explanation

A. The client tells the nurse he prefers a snack before bedtime: Client food preferences can usually be accommodated by nursing and dietary staff without needing interprofessional team intervention unless related to special dietary restrictions.

B. The client requires reinforcement of teaching about the purpose of his medications: Medication education reinforcement is a routine nursing responsibility and typically does not require escalation to the entire interprofessional team unless there are significant comprehension issues.

C. The client is unable to grasp eating utensils: Difficulty grasping utensils suggests significant motor deficits following the stroke. This functional limitation requires input from occupational therapy, physical therapy, and possibly speech therapy to assess needs for adaptive devices and rehabilitation strategies.

D. The client requests to perform ADLs later in the day: Adjusting the timing of ADLs is a minor scheduling preference and does not necessarily require interprofessional reporting unless it impacts therapy schedules or rehabilitation goals.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Seizures: The client’s symptoms of severe hypertension, persistent headache, hyperreflexia, proteinuria, and low platelet count strongly indicate severe preeclampsia, a condition that can rapidly progress to eclampsia, where seizures occur. This is a critical obstetric emergency requiring immediate intervention to prevent maternal and fetal morbidity.
Hypoglycemia: The client’s blood glucose level is 85 mg/dL, which is within the normal range. There are no signs such as diaphoresis, confusion, or weakness that would suggest hypoglycemia, and this condition is unrelated to the client's primary diagnosis of severe preeclampsia.
Cervical insufficiency: Cervical insufficiency typically causes painless cervical dilation and is associated with second-trimester pregnancy losses. The client is at 31 weeks with no reported cervical changes, contractions, or painless dilation, making this complication unlikely in the current clinical scenario.
Placental abruption: Severe hypertension increases the risk of placental abruption due to damage to the placental blood vessels. Signs of decreased fetal movement and the high-risk profile of preeclampsia support the concern that abruption could occur, leading to serious maternal and fetal compromise.
Heart failure: Although the client has some edema, there are no other clinical signs such as dyspnea, crackles, or orthopnea that would suggest heart failure. The edema seen here is consistent with preeclampsia rather than decompensated cardiac function.

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A nurse is collecting data from a client who has bipolar disorder. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team?

Correct Answer is C

Explanation

The nurse is continuing to assist with the care of the client. Select words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are ______ and ______

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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