Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an acute mental health unit is admitting a client who has bipolar disorder.
Which of the following findings supports the admitting diagnosis of acute mania?
A. The client's spouse reports that the client has recently gained weight.
Weight gain is not typically associated with acute mania in bipolar disorder.
B. The client responds to questions with disorganized speech.
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
C. The client reports that voices are telling him to write a novel.
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
D. The client is dressed in all black.
Dressing in all black is not a specific symptom of acute mania.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Custom Nurs 120 Psychiatric Nursing Fa23 Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale:
Weight gain is not typically associated with acute mania in bipolar disorder.
Choice B rationale:
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
Choice C rationale:
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
Choice D rationale:
Dressing in all black is not a specific symptom of acute mania.
Similar Questions
A nurse is reviewing the medical record of a client who performs self-injury.
Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?
A. The client has a history of bulimia nervosa.
While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.
B. The client has a parent who has dependent personality disorder.
Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.
C. The client has borderline personality disorder.
Borderline personality disorder is strongly associated with self-harm behaviors.
D. The client recently received a promotion at work.
Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.
Full Explanation
Choice A rationale:
While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.
Choice B rationale:
Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.
Choice C rationale:
Borderline personality disorder is strongly associated with self-harm behaviors.
Choice D rationale:
Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.
A nurse is conducting an in-service for a group of newly licensed nurses about the interventions used for clients experiencing non-suicidal self-harm (NSSH). Which of the following should the nurse include?.
A. Discourage clients from discussing the NSSH with friends.
Discouraging clients from discussing NSSH with friends may not be beneficial. Open communication can provide support and understanding.
B. Early recognition is crucial to successful treatment.
Early recognition is crucial to successful treatment. Timely intervention can prevent the escalation of self-harm behaviors and facilitate recovery.
C. Recognize non-suicidal self-harm as an attention-seeking behavior.
Recognizing NSSH as an attention-seeking behavior can be a misconception. NSSI is a complex behavior often associated with various underlying issues like emotional distress.
D. Ask the client why they do this as soon as possible.
Asking the client why they do this as soon as possible may not always be helpful. The focus should be on understanding their feelings and providing support.
Full Explanation
Choice A rationale:
Discouraging clients from discussing NSSH with friends may not be beneficial. Open communication can provide support and understanding.
Choice B rationale:
Early recognition is crucial to successful treatment. Timely intervention can prevent the escalation of self-harm behaviors and facilitate recovery.
Choice C rationale:
Recognizing NSSH as an attention-seeking behavior can be a misconception. NSSI is a complex behavior often associated with various underlying issues like emotional distress.
Choice D rationale:
Asking the client why they do this as soon as possible may not always be helpful. The focus should be on understanding their feelings and providing support.
A nurse is talking with a client who has schizophrenia.
Suddenly the client states, "I'm frightened.
Do you hear that? The voices are telling me to do terrible things.”. Which of the following responses by the nurse is appropriate?.
A. "What are the voices telling you to do?".
Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.
B. "Why do you think you are hearing the voices?".
Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.
C. "You need to understand that there are no voices.”.
Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.
D. "You need to tell the voices to leave you alone.”.
Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.
Full Explanation
Choice A rationale:
Asking “What are the voices telling you to do?” shows empathy and concern without validating the hallucination.
Choice B rationale:
Asking “Why do you think you are hearing the voices?” might imply that the nurse is validating the hallucination.
Choice C rationale:
Telling the client “You need to understand that there are no voices.”. might make the client feel misunderstood.
Choice D rationale:
Telling the client “You need to tell the voices to leave you alone.”. is not recommended as it might validate the hallucination.