A nurse is collecting data from a client who has bipolar disorder with mania.
Which finding is the nurse’s priority?

The client gives personal items and money away to other clients.

The client is hostile and sarcastic towards the staff.

The client paces in the hallway during the day and most of the night.

The client demonstrates flight of ideas.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. The client paces in the hallway during the day and most of the night.

Choice A rationale: Giving away personal items and money can indicate impulsivity and poor judgment, which are common in manic episodes. However, this behavior does not pose an immediate physical risk to the client or others.

Choice B rationale: Hostility and sarcasm towards staff can indicate irritability and agitation, which are also common in mania. While this behavior can disrupt the therapeutic environment, it is not the highest priority unless it escalates to physical aggression.

Choice C rationale: Pacing in the hallway during the day and most of the night indicates severe hyperactivity and potential exhaustion. This behavior poses a significant risk to the client’s physical health due to the possibility of dehydration, exhaustion, and other complications from lack of rest.

Choice D rationale: Demonstrating flight of ideas is a cognitive symptom of mania where the client rapidly shifts from one idea to another. While this can affect communication and thought processes, it does not pose an immediate physical risk.

In summary, the priority is to address behaviors that pose the greatest immediate risk to the client’s physical health and safety.

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Correct Answer is C

Explanation

Choice A rationale:

Psychomotor retardation is a characteristic of depression, not hypomania. In fact, individuals with hypomania typically exhibit psychomotor agitation, which is characterized by increased energy and activity levels.

Psychomotor retardation often manifests as slowed movements, speech, and thought processes. It can significantly impact an individual's ability to perform daily tasks and engage in social interactions.

While psychomotor retardation can occur in various mental health conditions, it is not typically associated with hypomania.

Choice B rationale:

Decreased self-esteem is also a characteristic of depression, not hypomania. Individuals with hypomania typically experience inflated self-esteem and grandiosity.

They may overestimate their abilities, make unrealistic plans, or engage in risky behaviors. This inflated sense of self-worth is often a hallmark feature of hypomania and can contribute to impaired judgment and decision-making.

Choice C rationale:

Euphoria is a hallmark symptom of hypomania. It is characterized by an elevated, expansive, or irritable mood that is persistent and noticeable to others.

Individuals with euphoria often feel excessively happy, cheerful, or optimistic. They may have increased energy, decreased need for sleep, and a heightened sense of well-being.

They may also be more talkative, outgoing, and engage in pleasurable activities more often.

This elevated mood is a core feature of hypomania and is often accompanied by other characteristic symptoms, such as increased activity levels, racing thoughts, and impulsivity.

Choice D rationale:

Hallucinations are not a typical feature of hypomania. They are more commonly associated with psychotic disorders, such as schizophrenia.

Hallucinations involve perceiving things that are not real, such as hearing voices or seeing things that are not there.

While hallucinations can occur in some individuals with hypomania, they are not a defining feature of the condition

A. Blood pressure and pulse rate B. Daily weight C. Food intake during meals D. Suicidal behavior

Correct Answer is ["A","B","D"]

Explanation

Answer and explanation The correct answers are:

Condition:

Mania Actions:
Daily weight

D. Suicidal behavior

Parameters to monitor:

Blood pressure and pulse rate

Food intake during meals

Rationale for condition:

Choice A: Mania

The client's presentation is consistent with the manic phase of bipolar disorder.

Key features of mania include:

Elevated mood or irritability

Increased energy and activity levels

Racing thoughts and rapid speech

Decreased need for sleep Impulsive behavior

Distractibility

Poor judgment

Grandiosity

Auditory hallucinations Rationale for actions:

Choice B: Daily weight

Weight loss is a common symptom of mania due to increased activity levels and decreased appetite.

Monitoring weight helps assess the severity of mania and the need for nutritional interventions.

Choice D: Suicidal behavior

Individuals with bipolar disorder are at increased risk for suicide, especially during manic episodes.

Close monitoring for suicidal ideation and behavior is crucial for safety.

Rationale for parameters to monitor:

Choice A: Blood pressure and pulse rate

Mania can lead to physiological changes such as increased heart rate and blood pressure.

Monitoring these vital signs helps assess the physical impact of mania and the potential need for medical interventions.

Choice C: Food intake during meals

As mentioned, decreased appetite is common in mania.

Monitoring food intake ensures adequate nutrition and prevents dehydration.

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A nurse is collecting data from a client who has bipolar disorder with mania. Which finding is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

Correct Answer is ["A","B","D"]

Explanation

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A nurse is collecting data from a client who has bipolar disorder with mania.
Which finding is the nurse’s priority?