A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?
Speaks in rhyming sentences
Makes inappropriate sexual comments
States that he hasn't bathed in 2 days
Reports eating twice in the past week
The Correct Answer is D
A. Speaking in rhyming sentences can be a manifestation of mania but may not necessarily require immediate reporting unless it escalates to disruptive or harmful behavior.
B. Making inappropriate sexual comments can indicate impulsivity and lack of social boundaries. It does not however precede managing the risk of hypoglycemia.
C. Poor hygiene, such as not bathing, is common in mania due to increased energy and decreased need for sleep, but it may not require immediate reporting unless it poses a significant risk to the client's health.
D. Decreased appetite and irregular eating patterns are common during mania due to increased activity levels. Eating twice in teh past is not sufficient to meet energy requirements and the client might be at risk of hypoglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This choice demonstrates an understanding of the importance of utilizing effective coping mechanisms.
B. Depending solely on a partner to plan daily activities may indicate dependence rather than self-care.
C. Remaining in bed excessively can perpetuate depressive symptoms and hinder recovery.
D. Avoiding discussing upsetting events may prevent processing emotions and hinder progress in therapy.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.
Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.
Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.
Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.
Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.
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