Nokea
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.
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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.
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.
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 patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300mg three times daily and has now reported being nauseated. To reduce the nausea, what will the nurse suggest the lithium be taken with?
- A. Food
- B. An antacid
- C. A large glass of juice
- D. An antiemetic medication
Correct Answer: A
Rationale: Taking lithium with food can reduce nausea. Other options are less effective or inappropriate for managing this side effect.
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.