A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

Choice A rationale:

Impulsive behaviors, such as sudden excessive spending, risky sexual encounters, or reckless driving, are common manifestations of manic behavior in individuals with bipolar disorder. These behaviors can result from the heightened energy and impulsivity associated with a manic episode.

Choice B rationale:

Dressing in black or grey clothing is not indicative of manic behavior. Mania is characterized by heightened mood, excessive energy, and impulsivity, rather than specific clothing choices.

Choice C rationale:

Talking in rapid, continuous speech, also known as pressured speech, is a classic symptom of manic episodes. Individuals may talk rapidly, switch topics frequently, and have difficulty allowing others to interject or participate in the conversation.

Choice D rationale:

Interacting with others in a flirtatious way can be a manifestation of manic behavior. During manic episodes, individuals may exhibit increased sociability, reduced inhibitions, and engage in behaviors that are out of character, including flirtatious interactions.

Choice E rationale:

Sleeping for long periods of time is not consistent with manic behavior. Manic episodes are often associated with decreased need for sleep, and individuals may experience insomnia or only require minimal sleep during these episodes.