a nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania which of the following findings is the nurses priori
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Nursing Elites

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ATI NCLEX PN Predictor Test

1. A nurse is collecting data from a client who has bipolar disorder and is experiencing acute mania. Which of the following findings is the nurse's priority?

Correct answer: C

Rationale: The correct answer is C: 'Lack of sleep.' In a client experiencing acute mania due to bipolar disorder, lack of sleep is the priority finding for the nurse to address. Sleep deprivation can exacerbate symptoms, lead to exhaustion, and increase the risk of further complications. Pressured speech, increased appetite, and mood swings are also common in acute mania, but addressing the lack of sleep takes precedence due to its significant impact on the client's well-being and recovery.

2. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?

Correct answer: B

Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.

3. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

4. A client with diabetes is being discharged. What is the most important teaching point?

Correct answer: B

Rationale: The most important teaching point for a client with diabetes being discharged is to administer insulin before meals as prescribed. This is crucial for managing blood sugar levels effectively and preventing complications. Monitoring blood sugar levels once in the morning (Choice A) is not sufficient for proper diabetes management, as levels can fluctuate throughout the day. Taking medication only when feeling unwell (Choice C) is not recommended as diabetes treatment is based on a regular schedule. Monitoring glucose levels weekly (Choice D) is not frequent enough to provide the necessary information for managing diabetes on a day-to-day basis.

5. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

Correct answer: B

Rationale: The correct answer is B: 'Demonstrate assertiveness.' For clients with dependent personality disorder, assertiveness training is crucial as it helps them become more independent and develop the skills to express their own needs and preferences effectively. Choice A ('Limit social interactions') is incorrect because promoting healthy social interactions is important for individuals with this disorder to build confidence and reduce dependency. Choice C ('Follow a rigid schedule') is incorrect as overly rigid schedules may exacerbate feelings of helplessness and dependence. Choice D ('Perform deep breathing exercises') is not directly related to addressing the core issues of dependent personality disorder, which primarily involve developing self-reliance and assertiveness.

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