A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

Correct answers: C, D, E

Choice A rationale:
While a consistent sleep schedule is important in the long term, a short nap during the day might be helpful for someone experiencing mania to prevent complete exhaustion, which can worsen symptoms.

Choice B rationale:
Weighing the client every 3 to 4 days (Choice B) might not be as crucial as the other options provided. While changes in weight can occur during mania, this intervention may not be as directly related to managing the acute symptoms of mania as other interventions.

Choice C rationale:
Maintaining an environment with low stimuli (Choice C) is essential during a manic episode. Clients with mania often experience heightened sensory sensitivity, and reducing environmental stimuli can help decrease agitation and promote a more stable mood.

Choice D rationale:
A client in a manic episode has increased caloric needs due to constant physical activity but may be unable to sit down for regular meals.Providing finger foods allows them to eat while remaining active.

Choice E rationale:

Mania can cause physiological changes like increased heart rate, blood pressure, and body temperature. Frequent monitoring helps detect potential complications and guide treatment decisions.

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.