A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
"You know we will not let you hit anyone. Why do you continue this behavior?"
"Do not hit anyone. If you are unable to control yourself, we will help you."
"Stop that! No one did anything to provoke an attack by you."
"If you do that one more time, you will be secluded immediately."
The Correct Answer is B
Rationale:
A. This approach is confrontational and accusatory, which may escalate agitation in a hyperactive or manic patient.
B. This response sets clear limits in a calm, supportive, and non-threatening manner, while also offering assistance with impulse control.
C. This statement is shaming and could escalate aggression rather than de-escalate the situation.
D. This is a threat rather than a therapeutic intervention, and it may increase the patient's agitation or resistance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Lemonade may mask the taste of lithium but does not significantly reduce gastrointestinal irritation.
B. Taking lithium with meals helps buffer the stomach lining, reducing nausea and other GI side effects.
C. A large glass of juice may dilute the medication but does not provide the same protective effect as food.
D. An antacid may help with indigestion, but it is not the primary recommendation for preventing nausea from lithium; additionally, some antacids can alter lithium absorption.
Correct Answer is A
Explanation
Rationale:
A. Energy drink containers may be counted because excessive caffeine intake can worsen agitation and mania symptoms. Monitoring caffeine consumption is relevant in manic episodes.
B. Hypodermic needles are not typically related to mania assessment unless substance abuse is suspected.
C. Empty soda cans may contain caffeine but energy drinks have a much higher caffeine concentration, making them more clinically relevant.
D. Fast food wrappers indicate diet but are less directly related to manic behavior management.
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