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. Shortness of breath and chronic cough are not typical early signs of lithium toxicity; these suggest possible respiratory or cardiac issues unrelated to lithium.
B. Early signs of lithium toxicity include gastrointestinal upset (nausea, diarrhea) and neuromuscular effects such as weakness.
C. ECG changes and chest pain can occur with severe toxicity, but they are not the most common initial symptoms.
D. Thirst may be a side effect of lithium due to nephrogenic diabetes insipidus, and nystagmus can occur in severe neurotoxicity, but these are not the classic early warning signs.
Correct Answer is B
Explanation
Rationale:
A. While depression may contribute to substance use, this choice makes an assumption about the patient's emotional state without adequate context.
B. Individuals with bipolar disorder often use substances like alcohol to manage or "self-medicate" their mood symptoms instead of taking prescribed medications.
C. This statement is overly simplistic and not clinically accurate; behavior is influenced by multiple factors, not just neurotransmitter levels.
D. While anxiety might coexist, this statement is vague and doesn't directly explain the pattern of substituting alcohol for prescribed medications.
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