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 B
Explanation
Rationale:
A. Arthritis does not typically affect lithium metabolism or clearance.
B. Heart failure can impair renal function and fluid balance, increasing the risk of lithium toxicity and making serum concentration monitoring critical.
C. Psoriasis does not interfere with lithium pharmacokinetics.
D. Epilepsy is not directly related to lithium metabolism, though caution is warranted if the patient is on other medications.
Correct Answer is C
Explanation
Rationale:
A. ECT is actually indicated for clients with severe depression or suicidal ideation when rapid symptom relief is necessary.
B. ECT is primarily used for acute treatment, not for relapse prevention. Maintenance medications are typically used to prevent relapse.
C. ECT can be an effective treatment for clients with severe manic episodes, especially when other treatments have failed or the client is a danger to themselves or others.
D. ECT is not first-line; mood stabilizers and antipsychotics are typically used first. ECT is reserved for treatment-resistant or severe cases.
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