A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?

Have the patient sit in his room while you review all the rules of the unit.

Reinforce previously learned coping mechanisms to calm the patient down.

Place the patient in a room with another hyperactive patient.

Administer antipsychotic medication as ordered and as needed by the physician.

Answer and Explanation

The Correct Answer is D

Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.

Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.

Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.

Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.

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Correct Answer is A

Explanation

Choice A reason: The myocardium requires a constant supply of oxygen to function properly. Coronary artery disease (CAD) causes a reduction in blood flow due to narrowed or blocked coronary arteries, leading to a lack of oxygen in the heart muscle, which can result in angina or chest pain.

Choice B reason: While increased cardiac workload can exacerbate chest pain, it is not the primary cause of pain in CAD. The pain is primarily due to ischemia, which is the lack of oxygen and nutrients to the heart tissue due to reduced blood flow.

Choice C reason: Interrupted electrical activity can lead to arrhythmias or heart attack, but it is not the direct cause of pain in CAD. The pain is related to ischemia, not electrical disturbances.

Choice D reason: A lack of nutrients, including oxygen, to the heart does contribute to the pain experienced in CAD; however, the primary factor is the insufficient oxygen supply, which is explicitly stated in choice A.

A. "Yes, I am happy for you." B. "No one can be great at everything." C. "Keep it up." D. "Tell me about a time in your life when things didn't go as planned."

Correct Answer is D

Explanation

Choice A reason: Affirming the patient's statement without addressing the potential for grandiosity may not be therapeutic.

Choice B reason: Telling a manic patient that no one can be great at everything may be confrontational and could escalate the situation.

Choice C reason: Encouraging the patient to "keep it up" may reinforce potentially harmful manic behavior.

Choice D reason: Asking the patient to recall a time when things didn't go as planned can help ground their thoughts and is a therapeutic communication technique used to address potential grandiosity in mania.

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A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

Correct Answer is A

Explanation

Your patient, who is manic, says, "Everything I do is great." How should you respond?

Correct Answer is D

Explanation

The nurse is reinforcing teaching to the patient about the cause of pain from coronary artery disease. The nurse would evaluate the patient as understanding the education if the patient stated which of the following causes the pain from coronary artery disease?

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