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: Difficulty concentrating is a common symptom of depression, particularly in individuals with a spinal cord injury, where the change in lifestyle and physical abilities can lead to cognitive overload and reduced focus.

Choice B reason: While paranoia can be associated with other mental health conditions, it is not a typical sign of depression. Depression is more commonly associated with symptoms like hopelessness and low self-esteem.

Choice C reason: Feelings of grandeur are not typically associated with depression. This symptom is more indicative of mania or other psychiatric conditions such as bipolar disorder.

Choice D reason: Flight of ideas is a symptom often seen in manic episodes and is characterized by rapidly changing or disjointed thoughts. It is not a common symptom of depression.

A. Encourage family to take the client out of the facility for short periods of time. B. Reward the client for her change in behavior. C. Ask the client why her behavior has changed. D. Monitor the client's whereabouts at all times.

Correct Answer is D

Explanation

Choice A reason: While it may be beneficial for the client's mood, taking the client out of the facility does not directly address the sudden change in behavior.

Choice B reason: Rewarding the client for a change in behavior does not address the potential risks associated with a sudden change in mental status.

Choice C reason: Asking the client why their behavior has changed could be part of an assessment, but it is not an immediate safety intervention.

Choice D reason: Monitoring the client's whereabouts at all times is important as a sudden lift in depressive symptoms can sometimes precede a suicide attempt, and close observation is necessary.

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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

A nurse is caring for a client who has a spinal cord injury and is at risk for depression. Which of the following findings should the nurse identify as an indication that the client is developing depression?

Correct Answer is A

Explanation

A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?

Correct Answer is D

Explanation

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