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. Energy drink containers may be counted because excessive caffeine intake can worsen agitation and mania symptoms. Monitoring caffeine consumption is relevant in manic episodes.
B. Hypodermic needles are not typically related to mania assessment unless substance abuse is suspected.
C. Empty soda cans may contain caffeine but energy drinks have a much higher caffeine concentration, making them more clinically relevant.
D. Fast food wrappers indicate diet but are less directly related to manic behavior management.
Correct Answer is B
Explanation
Rationale:
A. Arthritis does not typically affect lithium metabolism or clearance.
B. Heart failure can impair renal function and fluid balance, increasing the risk of lithium toxicity and making serum concentration monitoring critical.
C. Psoriasis does not interfere with lithium pharmacokinetics.
D. Epilepsy is not directly related to lithium metabolism, though caution is warranted if the patient is on other medications.
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