A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply).
Social isolation
Impaired mood regulation
Imbalanced nutrition: more than body requirements
Chronic confusion
Sleep deprivation
Correct Answer : B,E
Rationale:
A. Social isolation is more typical in depression or withdrawal, not acute mania, where patients are often excessively social or intrusive.
B. Impaired mood regulation is characteristic of mania, involving mood swings, irritability, and poor impulse control.
C. Imbalanced nutrition: more than body requirements is unlikely during mania; patients often have decreased appetite.
D. Chronic confusion is not typical in acute mania; cognitive impairment may be present but is usually not chronic.
E. Sleep deprivation is common in manic episodes due to decreased need for sleep and hyperactivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Severe diarrhea, worsening tremor, weakness, and unsteady gait are signs of possible lithium toxicity, which requires immediate medical evaluation; the patient should be brought to the clinic promptly.
B. Restricting fluids can worsen dehydration and increase lithium concentration, making toxicity more likely.
C. Taking an antidiarrheal does not address the underlying problem and may delay urgent treatment.
D. Adding salt and water will not reverse toxicity and could delay necessary medical intervention.
Correct Answer is B
Explanation
Rationale:
A. Bipolar I disorder involves episodes of full mania, not just hypomania.
B. Bipolar II disorder is characterized by alternating episodes of hypomania and major depression (often mild to moderate).
C. Cyclothymic disorder involves milder mood swings but does not meet criteria for hypomania or major depression.
D. Schizophrenia is a psychotic disorder, not primarily a mood disorder with hypomanic and depressive episodes.
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