Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.).
A. Dressing in black or grey clothing.
Dressing in black or grey clothing is not a specific indicator of manic behavior. A client's choice of clothing may be influenced by personal preferences, cultural norms, or other factors unrelated to their mood state. While changes in clothing style could be associated with mood changes, it's not a definitive sign of manic behavior.
B. Spending large sums of money.
Spending large sums of money is indicative of manic behavior commonly seen in bipolar disorder's manic phase. During this phase, individuals might engage in impulsive and reckless behaviors, including excessive spending sprees, often without consideration of the consequences. This behavior is driven by the elevated mood and decreased impulse control associated with mania.
C. Interacting with others in a flirtatious way.
Interacting with others in a flirtatious way is another manifestation of manic behavior. During manic episodes, individuals might exhibit heightened sociability, increased confidence, and diminished inhibitions. Flirtatious behavior can be a result of this heightened social engagement and may not reflect the individual's typical personality traits.
D. Talking in rapid, continuous speech.
Talking in rapid, continuous speech, often referred to as "pressured speech," is a classic symptom of manic behavior. The individual talks rapidly, with abrupt topic changes and a sense of urgency. This symptom is reflective of the racing thoughts and increased energy levels experienced during a manic episode.
E. Sleeping for long periods of time.
Sleeping for long periods of time is not characteristic of manic behavior. In fact, during manic episodes, individuals often experience a decreased need for sleep, known as insomnia or hypersomnia. This reduced need for sleep contributes to the overall restlessness and high energy levels seen in mania.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Similar Questions
A nurse caring for a client who has depression observes the client coming to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
A. "Everyone feels better after showering.".
"Everyone feels better after showering." Rationale: This response minimizes the client's efforts and feelings. Depression can often make even simple tasks like showering feel daunting, so this response doesn't acknowledge the client's achievement appropriately.
B. "Why are you all dressed up today? Is it a special occasion?".
"Why are you all dressed up today? Is it a special occasion?" Rationale: This response implies that there must be a special reason for the client's improved appearance. It could inadvertently put pressure on the client to come up with a justification for their self-care, potentially causing discomfort.
C. "You must be getting better. You look great!".
"You must be getting better. You look great!" Rationale: This response acknowledges the client's efforts and highlights their positive change. It offers encouragement and support without assuming or questioning motives. It's a positive reinforcement that can help boost the client's self-esteem.
D. "I see you have done some grooming today.".
"I see you have done some grooming today." Rationale: While this response acknowledges the client's grooming, it lacks the positive and affirming tone of choice C. It focuses on the observation rather than expressing encouragement or recognition for the client's progress.
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
A. "My child was born with a birth defect due to an exposure I had overseas.".
"My child was born with a birth defect due to an exposure I had overseas." Rationale: This statement doesn't directly relate to the symptoms of posttraumatic stress disorder (PTSD) such as re-experiencing trauma, hyperarousal, and avoidance behaviors. It might be related to guilt or remorse but doesn't fit the profile of PTSD.
B. "I killed four enemy soldiers with my bare hands and saved my entire battalion.".
"I killed four enemy soldiers with my bare hands and saved my entire battalion." Rationale: While this statement suggests exposure to combat and a traumatic event, it lacks the hallmark symptoms of PTSD. It might indicate desensitization to violence, but it doesn't necessarily reflect the intrusive thoughts and hyperarousal commonly seen in PTSD.
C. "I check any room I enter because the enemy is still after me and could be hiding anywhere.".
"I check any room I enter because the enemy is still after me and could be hiding anywhere." Rationale: This statement reflects hyperarousal, hypervigilance, and re-experiencing symptoms characteristic of PTSD. The client's behavior of checking rooms for threats demonstrates a persistent sense of danger and vigilance even in safe environments.
D. "In my dreams, all I can see are the wounded reaching out and trying to grab me.".
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
A. Medicate the client with a sedative.
"Medicate the client with a sedative." Rationale: Medicating the client immediately with a sedative might provide short-term relief, but it doesn't address the underlying anxiety or promote coping strategies. Using medication as the first response can also create dependence and hinder the development of healthy coping mechanisms.
B. Suggest that the client rest in bed.
"Suggest that the client rest in bed." Rationale: Suggesting rest in bed might not be the most appropriate action for someone with panic-level anxiety. It could lead to rumination and increased anxiety while alone. Direct interventions are generally more effective in managing acute anxiety.
C. Have the client join a therapy group.
"Have the client join a therapy group." Rationale: While therapy groups can be beneficial, they might overwhelm the client in an acute state of panic-level anxiety. The client's ability to engage in a group setting could be compromised at this moment.
D. Remain with the client for a while.
"Remain with the client for a while." Rationale: This choice provides immediate support and reassurance to the client. Presence and active listening from the nurse can help calm the client's anxiety and create a sense of safety. Once the acute anxiety subsides, other interventions like therapy groups can be explored.