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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.
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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.
A health teaching plan for a patient taking lithium should include which instructions?
- A. Maintain normal salt and fluids in the diet.
- B. Drink twice the usual daily amount of fluids.
- C. Double the lithium dose if diarrhea or vomiting occurs.
- D. Avoid eating aged cheese, processed meats, and red wine.
Correct Answer: A
Rationale: Maintaining normal salt and fluid intake prevents lithium toxicity. Other options are incorrect or unrelated to lithium therapy.
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.
A patient tells the nurse, 'I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such a burden to my family.' These statements support which nursing diagnoses?
- A. Powerlessness
- B. Defensive coping
- C. Chronic low self-esteem
- D. Impaired social interaction
- E. Risk-prone health behavior
Correct Answer: A,C
Rationale: The patient's shame and perceived burden reflect chronic low self-esteem and powerlessness. Other diagnoses are not supported by the statements.
A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention?
- A. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing.
- B. Continue to monitor and document the patient's speech patterns and motor activity.
- C. Ask the health care provider to prescribe an increased dose and frequency of lithium.
- D. Consider the need to check the lithium level. The patient may not be swallowing medications.
Correct Answer: D
Rationale: Persistent manic symptoms suggest possible nonadherence, warranting a lithium level check. Increasing the dose or other options are less appropriate.