A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply.)

Grandiosity

Flight of ideas

Splitting

Hyperactivity

Answer and Explanation

Correct Answer : A,B,D

Choice A reason:

Grandiosity is a common symptom of a manic episode. Clients may have an inflated sense of self-importance and believe they have special abilities or powers.

Choice B reason:

Flight of ideas is characterized by rapid and continuous speech with frequent changes in topic. This is a typical behavior during a manic episode.

Choice C reason:

Splitting, which involves viewing people or situations as all good or all bad, is more commonly associated with borderline personality disorder rather than bipolar disorder.

Choice D reason:

Hyperactivity is a hallmark of mania. Clients may exhibit increased energy levels, restlessness, and engage in excessive activities.

Choice E reason:

Withdrawal is not typically associated with manic episodes. It is more commonly seen in depressive episodes or other mental health conditions.

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Correct Answer is D

Explanation

Choice A reason:

Agreeing with the parent and assuming the situation will not happen again is not appropriate. It dismisses the potential risk to the child and does not address the seriousness of the situation.

Choice B reason:

Telling the parent to file charges against their partner is a strong directive that may not be appropriate without further understanding of the situation. It is important to gather more information before making such recommendations.

Choice C reason:

Stating that the situation is clearly child endangerment and immediately calling the police may escalate the situation without fully understanding the context. It is important to assess the situation thoroughly before taking such actions.

Choice D reason:

Expressing a desire to know more about what happened and offering to talk is an appropriate response. It allows the nurse to gather more information, assess the situation, and provide support to the parent and child.

A. Document the client’s behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff. D. Request an evaluation of the client within 12 hours of application of restraints.

Correct Answer is D

Explanation

Choice A reason: Documenting the client’s behavior once every hour is important for monitoring the client’s condition and ensuring their safety. However, it is not the most immediate action to take after applying restraints.

Choice B reason: Keeping the client in restraints until the prescription expires is not appropriate. Restraints should be used for the shortest duration necessary and should be removed as soon as the client is no longer a threat to themselves or others.

Choice C reason: Conducting a debriefing with the unit staff is important for reviewing the incident and planning future care. However, it is not the immediate action required after applying restraints.

Choice D reason: Requesting an evaluation of the client within 12 hours of applying restraints is crucial. This ensures that the client’s condition is reassessed, and the need for continued restraints is evaluated. It also helps in planning further interventions to manage the client’s aggressive behavior.

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A nurse is conducting an admission assessment for a client who is experiencing a manic episode of bipolar disorder. Which of the following behaviors should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child’s parent states, “My partner got fired today and came home angry. I don’t think this will happen again.” Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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