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.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Restraining should only be used as a last resort when the patient poses an imminent danger to self or others, not as an initial intervention.
B. Allowing the patient to act out feelings without limits can lead to unsafe behaviors and escalate manic symptoms.
C. Setting limits on behavior provides structure, maintains safety, and helps the patient with mania feel more secure and contained.
D. Providing verbal instructions to remain calm is ineffective in acute mania, as the patient’s ability to process and follow directions is impaired.
Correct Answer is C
Explanation
Rationale:
A. Dysthymic disorder is a chronic mild depression and typically does not require intensive supervision.
B. Bipolar II disorder involves hypomania and depression but less severe mania than Bipolar I.
C. Bipolar I disorder includes full manic episodes which can involve risky, impulsive, or aggressive behavior requiring close supervision for safety.
D. Cyclothymic disorder involves milder mood swings and generally lower risk behaviors.
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