When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention?
Restrain the patient to reduce hyperactivity and aggression
Allow the patient to act out feelings
Set limits on patient behavior as necessary
Provide verbal instructions to the patient to remain calm
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A lithium serum level between 0.6 and 1.2 mEq/L is generally considered within the therapeutic range for maintenance treatment.
B. Above therapeutic limits would typically be >1.5 mEq/L, which increases toxicity risk.
C. While timing of blood draw is important, an 8-hour interval is acceptable for monitoring lithium levels (usually drawn 12 hours post-dose but 8 hours is still interpretable).
D. A level of 1 mEq/L is not below therapeutic limits.
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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