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. Poor judgment and hyperactivity are characteristic of mania, demonstrated by risky behavior (posting on official sites, inviting politicians) and prolonged activity without rest.
B. Increased muscle tension and anxiety are more typical of anxiety disorders, not classic manic episodes.
C. Vegetative signs (e.g., sleep and appetite disturbances) occur but poor grooming is more common in depression than mania.
D. Cognitive deficits and paranoia may be seen in psychosis but are not the primary features described here.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.