A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

Exhibiting clang associations

interacting with others in a flirtatious way

Reports sleeping for long periods of time

Talking in rapid continuous speech

Reports spending large sums of money

Answer and Explanation

Correct Answer : A,B,D,E

A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.

B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.

C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.

D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.

E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.

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Correct Answer is A

Explanation

A. Set limits on the amount of time the client talks about delusions.Clients with paranoid delusions may fixate on them, increasing distress and reinforcing their beliefs. The nurse should allow the client to express feelings but set limits on discussions about delusions to help refocus on reality-based topics.

B. Schedule a variety of competitive stimulating group activities for the client.Competitive activities can increase stress and paranoia in a client with schizophrenia. Instead, the nurse should encourage structured, low-stimulation activities like drawing or walking.

C. Tell the client that the delusions are not real. Directly challenging the delusions can increase defensiveness and mistrust.

D. Avoid asking the client about triggers for the delusions. Identifying triggers can help prevent or manage delusional episodes. The nurse should gently explore what makes the client feel more paranoid or anxious to develop coping strategies.

A. Check the bruises at the next visit to the client's home. B. Follow the agency's guidelines for reporting suspected abuse. C. Institute more frequent visits to the client's home. D. Arrange referral for family therapy to deal with home stressors.

Correct Answer is B

Explanation

A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.

B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.

C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.

D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.

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A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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