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. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

A. Gloves B. Gown C. Dosimeter badge D. N95 respirator

Correct Answer is D

Explanation

A. Gloves: Gloves are important for contact precautions but are not sufficient protection against airborne infections like tuberculosis. Tuberculosis spreads through respiratory droplets that remain suspended in the air, requiring specialized respiratory protection.

B. Gown: A gown is generally used when there is a risk of direct contact with infectious material. While gowns are important for many isolation precautions, they do not protect against airborne transmission of tuberculosis.

C. Dosimeter badge: A dosimeter badge measures exposure to radiation, not infectious agents. It is used in environments with radiologic procedures and is unrelated to protecting against infectious diseases like tuberculosis.

D. N95 respirator: An N95 respirator is specifically designed to filter airborne particles, including Mycobacterium tuberculosis. It fits tightly around the face and provides the necessary protection against inhaling infectious airborne pathogens in the client’s environment.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

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 collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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