A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
Ignore the client's behavior, realizing it is consistent with her illness.
Set limits on the client's behavior and be consistent in approach.
Ask the client to recommend consequences for her disruptive behavior.
Warn the client that further disruptions will result in seclusion.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
No explanation
Correct Answer is C
Explanation
A.While it is important to understand changes in behavior, the sudden shift from depression to a cheerful state could be indicative of a potential risk, such as a plan to self-harm, particularly if the client is showing improved mood quickly.
B.It is not appropriate to reward a change in behavior without understanding the underlying reasons for the change. The sudden improvement in mood could be a sign of a potential risk, such as suicidal ideation or a temporary lift in mood before a possible crisis.
C.This is a crucial intervention. A sudden change in mood can sometimes be associated with an increased risk of self-harm or suicidal ideation, particularly if the client’s mood improves significantly before a more stable improvement in their depressive symptoms. Continuous monitoring helps ensure the client’s safety.
D.This could be premature and potentially unsafe, given the sudden and significant change in the client's condition. It is more important to ensure that the client’s mood change is not indicative of an underlying risk before allowing unsupervised activities.
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