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 C
Explanation
Rationale:
A. This indicates continued manic behavior such as distractibility and impulsivity, suggesting the treatment has not yet been effective.
B. These symptoms are consistent with acute mania, including poor sleep and distractibility, showing that the condition persists.
C. This reflects improvement in mood, behavior, and thought organization, indicating that the treatment is effective.
D. These are signs of ongoing manic behavior, especially impulsivity and rapid, excessive speech.
Correct Answer is A
Explanation
Rationale:
A. Painting is a solitary, creative activity that requires minimal cognitive processing and social interaction, making it suitable for clients experiencing disturbed thoughts.
B. Playing cards requires attention to rules and interaction, which might be difficult during disturbed thoughts.
C. Playing board games often requires sustained concentration and social engagement, which may be overwhelming initially.
D. Playing checkers also requires strategy and focus, which may not be appropriate during acute thought disturbances.
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