a nurse is assessing a client with suspected bipolar disorder which of the following findings shouldnt the nurse expect
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Nursing Elites

ATI RN

ATI Mental Health

1. When assessing a client with suspected bipolar disorder, which of the following findings should the nurse not expect?

Correct answer: D

Rationale: In bipolar disorder, common findings include periods of elevated mood, decreased need for sleep, and flight of ideas. Anhedonia, the inability to feel pleasure, is more indicative of conditions like major depressive disorder. Therefore, the nurse should not expect to find anhedonia in a client with suspected bipolar disorder.

2. A client with borderline personality disorder exhibits self-mutilating behavior. Which nursing intervention should the nurse implement to address this behavior?

Correct answer: C

Rationale: The correct intervention when dealing with a client exhibiting self-mutilating behavior, especially with borderline personality disorder, is to provide a safe environment to prevent self-harm. This approach is crucial in ensuring the client's physical safety and well-being. Setting firm limits may be appropriate in some situations, but the immediate priority is to prevent self-harm. Encouraging the client to discuss underlying issues and discussing consequences are important aspects of therapy; however, in the case of acute self-mutilating behavior, the primary focus should be on creating a safe environment to prevent harm.

3. A client with bipolar disorder is experiencing a depressive episode. Which nursing intervention is most appropriate?

Correct answer: C

Rationale: Encouraging the client to participate in group therapy is the most appropriate nursing intervention for a client with bipolar disorder experiencing a depressive episode. Group therapy provides a supportive environment where the client can share experiences, learn coping strategies, and receive emotional support from peers and mental health professionals. It can help reduce feelings of isolation, improve social skills, and enhance overall well-being. Group therapy also promotes a sense of belonging and understanding, which are essential for individuals dealing with bipolar disorder and depressive symptoms. Choices A, B, and D are not the most appropriate interventions for a client experiencing a depressive episode in bipolar disorder. Encouraging the client to avoid physical activity may worsen their symptoms, promoting social activities may not address the underlying issues effectively, and setting goals may be overwhelming during a depressive episode.

4. A patient with posttraumatic stress disorder (PTSD) is experiencing flashbacks. The most appropriate intervention is to:

Correct answer: B

Rationale: When a patient with PTSD is experiencing flashbacks, the most appropriate intervention is to help them reorient to the present. This intervention can assist in reducing the intensity of the flashback and providing a sense of safety for the patient. Choice A is incorrect because encouraging the patient to talk about the trauma during a flashback may exacerbate their distress. Choice C is incorrect as leaving the patient alone can increase their feelings of isolation and fear. Choice D is incorrect because reminding the patient that the flashback is not real may invalidate their experience and increase their sense of disconnection.

5. A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings should the healthcare professional expect? Select one that doesn't apply.

Correct answer: D

Rationale: Findings in a client diagnosed with anorexia nervosa include amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa. In anorexia nervosa, electrolyte imbalances often lead to hypokalemia, which is low potassium levels, due to malnutrition and potential purging behaviors. Hyperkalemia, high potassium levels, is not a common finding in individuals with anorexia nervosa.

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