The nurse observes a client who is rapidly pacing, wringing their hands, and trembling. Their speech is high-pitched, they are unable to concentrate, and have restricted problem-solving. The nurse identifies the client’s anxiety level as:

Choice A reason: Daily weight monitoring and reporting a 3-pound gain in one day indicates fluid retention, a sign of worsening heart failure. This is correct and shows understanding of self-monitoring to prevent complications, requiring no further teaching.

Choice B reason: Notifying the provider about increasing shortness of breath at rest is appropriate, as it signals worsening heart failure due to reduced cardiac output or pulmonary edema. This reflects proper understanding of symptom monitoring, requiring no additional teaching.

Choice C reason: A low-sodium diet reduces fluid retention in heart failure by decreasing sodium-induced water retention, preventing worsening of edema or congestion. This statement is correct and demonstrates understanding of dietary management, requiring no further teaching.

Choice D reason: Sleeping in a reclining chair may occur in severe heart failure due to orthopnea, but it is not a standard recommendation. It suggests poor symptom control, requiring further teaching on optimizing medical management, such as medication adherence and fluid monitoring, to prevent this need.

Choice A reason: Feelings of grandiosity are more characteristic of mania in bipolar I disorder. Hypomania in bipolar II involves milder elevated mood, energy, and confidence without extreme grandiosity, making this symptom less consistent with a hypomanic episode.

Choice B reason: Total loss of interest in activities is a depressive symptom, not hypomania. Hypomanic episodes involve increased energy and engagement in activities, often with heightened productivity or creativity, making this inconsistent with the client’s current state.

Choice C reason: Decreased need for sleep is a hallmark of hypomania in bipolar II, where clients feel rested after minimal sleep due to heightened energy from altered dopamine and norepinephrine activity. This is highly consistent with hypomanic episodes, distinguishing it from mania.

Choice D reason: Severe depressive moods characterize the depressive phase of bipolar II, not hypomania. Hypomanic episodes involve elevated mood and energy, contrasting with the low mood and fatigue of depression, making this inconsistent.