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A patient experiencing acute mania waves a newspaper and says, 'I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes.' What is the nurse's most appropriate intervention?
- A. Suggesting to the patient to ask a friend to do the shopping and bring purchases to the unit
- B. Inviting the patient to sit with the nurse and look at new fashion magazines
- C. Telling the patient that computer use is not allowed until self-control improves
- D. Asking whether the patient has enough money to pay for the purchases
Correct Answer: B
Rationale: Distraction with fashion magazines leverages the patient's distractibility to avoid power struggles and reduce impulsive behavior. Other options may escalate frustration.
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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.
What is the focus of outcome identification for the treatment plan of a patient presenting with grandiose thinking associated with acute mania?
- A. Maintaining an interest in the environment
- B. Developing an optimistic outlook
- C. Self-control of distorted thinking
- D. Stabilizing the sleep pattern
Correct Answer: C
Rationale: Controlling grandiose thinking is the primary outcome, as it addresses the core symptom of mania. Other options are less directly related.
A nurse prepares the plan of care for a patient experiencing a manic episode. Which nursing diagnoses are most appropriate?
- A. Imbalanced nutrition: more than body requirements
- B. Disturbed thought processes
- C. Sleep deprivation
- D. Chronic confusion
- E. Social isolation
Correct Answer: B,C
Rationale: Manic patients often experience disturbed thought processes and sleep deprivation due to hyperactivity. Other diagnoses are less relevant or incorrect.
A patient prescribed lithium telephones the nurse at the clinic to say, 'I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?' What instructions should the nurse provide?
- A. Restrict oral fluids for 24 hours and stay in bed.'
- B. Have someone bring you to the clinic immediately.'
- C. Drink a large glass of water with 1 teaspoon of salt added.'
- D. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.'
Correct Answer: B
Rationale: Symptoms suggest lithium toxicity, requiring immediate evaluation. Other options may worsen the condition or delay treatment.
A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine. This is the expected reaction to the addition of olanzapine to the medication regimen?
- A. Minimize the side effects of lithium.
- B. Bring hyperactivity under rapid control.
- C. Enhance the antimanic actions of lithium.
- D. Provide long-term control of hyperactivity.
Correct Answer: B
Rationale: Olanzapine has a rapid onset to control hyperactivity initially, as lithium requires time to reach therapeutic levels. It does not enhance lithium's effects or minimize side effects.