Nokea
A patient experiencing acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement?
- A. Place the patient in the seclusion room.
- B. Ask if the patient finds clothes bothersome.
- C. Tell the patient that others feel embarrassed.
- D. Arrange for one-on-one supervision.
Correct Answer: D
Rationale: One-on-one supervision provides structure to prevent repeated disrobing. Seclusion is not warranted, and other options are ineffective.
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Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical?
- A. Arthritis
- B. Epilepsy
- C. Exercise-induced asthma
- D. Congestive heart failure
Correct Answer: D
Rationale: Congestive heart failure and diuretic use complicate fluid balance, increasing lithium toxicity risk. Other conditions do not directly affect lithium monitoring.
A nurse reviewing the laboratory results for a patient diagnosed with bipolar disorder notes the lithium level as 1 mEq/L. How will the nurse interpret this information about the medication level?
- A. It requires no additional nursing intervention.
- B. It is below recognized therapeutic serum limits.
- C. It is above recognized therapeutic serum limits.
- D. It indicates a need for immediate medical intervention.
Correct Answer: A
Rationale: A lithium level of 1 mEq/L is within the therapeutic range (0.4-1 mEq/L), requiring no further intervention.
A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, 'Do I have to keep taking this lithium even though my mood is stable now?' Select the nurse's most appropriate response.
- A. You will be able to stop the medication in approximately 1 month.'
- B. Taking the medication every day helps prevent relapses and recurrences.'
- C. Usually patients take this medication for approximately 6 months after discharge.'
- D. It's unusual that the health care provider has not already stopped your medication.'
Correct Answer: B
Rationale: Lithium maintenance prevents recurrences, and this response promotes compliance. Other options provide incorrect information.
A patient experiencing acute mania undresses in the group room and dances. What should be the nurse's first intervention?
- A. Quietly ask the patient, 'Why don't you put on your clothes?'
- B. Firmly tell the patient, 'Stop dancing, and put on your clothing.'
- C. Put a blanket around the patient and walk with the patient to a quiet room.
- D. Allow the patient stay in the group room while moving the other patients to a different area.
Correct Answer: C
Rationale: Covering the patient and removing them from the area protects them from embarrassment and maintains safety. Other options are less effective or inappropriate.
Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective?
- A. Converses without interrupting; clothing matches; participates in activities.'
- B. Irritable, suggestible, distractible; napped for 10 minutes in afternoon.'
- C. Attention span short; writing copious notes; intrudes in conversations.'
- D. Heavy makeup; seductive toward staff; pressured speech.'
Correct Answer: A
Rationale: Appropriate behavior and participation without overstimulation indicate effective treatment. Other options reflect ongoing manic symptoms.