A patient diagnosed with bipolar disorder is dressed in a purple leopard and bright floral scarves. The patient twirls and shadow boxes. The patient says gaily. "Do you like my scarves? Here they are my gift to you." How should the nurse document the patient's mood?

Irritable

Suspicious

Euphoric

Confident

Answer and Explanation

The Correct Answer is C

A. Irritability involves anger, frustration, or easily annoyed behavior, which is not reflected in the patient’s joyful and playful actions.

B. Suspicious mood would include mistrust or paranoia, which is not evident in this patient’s behavior.

C. Euphoric mood is characterized by exaggerated feelings of well-being, elation, or joy, often with energetic and flamboyant behavior, as demonstrated by twirling, shadow boxing, and offering scarves as gifts.

D. Confidence refers to self-assurance and poise without the intense elation or overexcitement seen in euphoria.

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Correct Answer is C

Explanation

A. Respecting confidentiality is important, but the nurse has a legal and ethical duty to report child abuse, even if the patient discloses it in confidence.

B. Filing a report with the ethics committee does not fulfill the mandatory reporting requirement for child abuse.

C. The nurse must report suspected or disclosed child abuse to the appropriate child protection agency, even if the patient is now in rehabilitation. Anonymity may be used if allowed, but reporting is legally required.

D. Reassuring the patient about comfort in sharing does not address the immediate need to protect the child and fulfill mandatory reporting obligations.

A. "You know we will not let you hit anyone. Why do you continue this behavior? B. "Do not hit anyone. If you are unable to control yourself, we will help you." C. "Stop that! No one did anything to provoke an attack by you." D. "If you do that one more time, you will be secluded immediately."

Correct Answer is B

Explanation

A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient.

B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way.

C. This is judgmental and blaming, which is not therapeutic and may increase hostility.

D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.

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A patient diagnosed with bipolar disorder is dressed in a purple leopard and bright floral scarves. The patient twirls and shadow boxes. The patient says gaily. "Do you like my scarves? Here they are my gift to you." How should the nurse document the patient's mood?

Nursing Test Bank

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Correct Answer is C

Explanation

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