Nokea
A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient cusses while twirling and shadowboxing. Then the patient says gaily, 'Do you like my scarves? Here... they are my gift to you.' How should the nurse document the patient's mood?
- A. Labile and euphoric
- B. Irritable and belligerent
- C. Highly suspicious and arrogant
- D. Excessively happy and confident
Correct Answer: A
Rationale: The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile.
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A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
- A. Stop that! No one did anything to provoke an attack by you.'
- B. If you do that one more time, you will be secluded immediately.'
- C. Do not hit anyone. If you are unable to control yourself, we will help you.'
- D. You know we will not let you hit anyone. Why do you continue this behavior?'
Correct Answer: C
Rationale: Setting limits in simple, concrete terms helps de-escalate the situation while offering assistance. The other options either threaten punishment or fail to provide environmental safety.
Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania?
- A. Spaghetti and meatballs, salad, a banana
- B. Beef and vegetable stew, a roll, chocolate pudding
- C. Broiled chicken breast on a roll, an ear of corn, apple
- D. Chicken casserole, green beans, flavored gelatin with whipped cream
Correct Answer: C
Rationale: Finger foods like chicken on a roll and corn allow the hyperactive patient to eat on the go. Other options require utensils, which may be impractical.
After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication?
- A. Decreasing physical activity
- B. Increasing food and fluids
- C. Meeting self-care needs
- D. Psychoeducation
Correct Answer: D
Rationale: Psychoeducation promotes medication adherence and relapse prevention, which are critical post-discharge. Other options are less prioritized.
When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority?
- A. Allowing the patient to act out his or her feelings
- B. Setting limits on the patient's behavior as necessary
- C. Providing verbal instructions to the patient to remain calm
- D. Restraining the patient to reduce hyperactivity and aggression
Correct Answer: B
Rationale: Setting limits provides structure and support while the patient's control is tenuous, prioritizing safety. Other options may escalate behavior or are inappropriate initially.
A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
- A. Risk for injury
- B. Ineffective coping
- C. Impaired social interaction
- D. Ineffective therapeutic regimen management
Correct Answer: A
Rationale: Hyperactivity and poor judgment place the patient at risk for injury, making this the priority nursing diagnosis to ensure physiological safety.