A client diagnosed with bipolar disorder is admitted to an inpatient psychiatric facility with acute mania and threats of attacking others in the household. Which would be the priority?
Challenging the client's behavior
Ensuring safety
Administering mood stabilizers
Removing the client to a quiet environment
The Correct Answer is B
Choice A reason: Challenging a client's behavior during an acute manic episode with threats of violence is a contraindicated and potentially dangerous nursing intervention. Clients in acute mania exhibit elevated irritability, impulsivity, poor impulse control, and a low threshold for aggressive responses when they perceive provocation or confrontation. Challenging behavior in this context risks escalating agitation and precipitating physical violence against staff, other clients, or property. Evidence-based de-escalation strategies for acute mania emphasize non-confrontational, calm, and structured communication rather than behavioral challenge, and standard psychiatric nursing guidelines consistently advise against confrontational approaches with acutely agitated clients.
Choice B reason: Ensuring safety is the overriding priority in this clinical scenario, consistent with both the nursing priority framework based on Maslow's hierarchy and the standards of psychiatric-mental health nursing practice. The client presents with acute mania, characterized by severely impaired judgment, psychomotor agitation, and explicit threats of physical violence toward household members. This constitutes an immediate risk of harm to others, which must be addressed before any other intervention. Safety encompasses protection of the client, staff, and third parties through environmental management, de-escalation, team communication, and, when necessary, pharmacological or physical interventions within the therapeutic and legal framework.
Choice C reason: Administering mood stabilizers, such as lithium carbonate, valproate (divalproex), or atypical antipsychotics such as quetiapine or olanzapine, is an essential component of the pharmacological management of acute mania in bipolar disorder. These agents reduce the severity and duration of manic episodes by modulating dopaminergic, serotonergic, and glutamatergic neurotransmission. However, mood stabilizers have a delayed onset of therapeutic effect, particularly lithium, which requires days to weeks to reach therapeutic serum levels. In the acute setting with immediate threats of violence, medication administration is a secondary intervention that supports safety goals but cannot be the first priority when immediate physical danger is present.
Choice D reason: Removing the client to a quiet, low-stimulation environment is a recognized and effective de-escalation strategy for managing acute mania, as excessive environmental stimuli can exacerbate psychomotor agitation and escalate behavioral dysregulation in manic episodes. Reducing sensory input — including noise, activity, and social stimulation — helps decrease arousal and facilitates de-escalation. However, environmental modification is a specific tactical intervention within the broader framework of ensuring safety. It addresses one dimension of the safety priority but is subordinate to the overarching goal of ensuring the physical safety of all individuals, including the client and potential victims of threatened violence.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Trusting behaviors are not characteristic of schizotypal personality disorder. According to the DSM-5, schizotypal personality disorder is defined by a pervasive pattern of social and interpersonal deficits, including marked discomfort with and reduced capacity for close relationships, as well as cognitive and perceptual distortions and eccentric behaviors. Individuals with this disorder typically exhibit pervasive suspiciousness and paranoid ideation in social situations, making trust difficult to establish or maintain. Describing trusting behavior as a characteristic of this disorder is clinically inaccurate.
Choice B reason: Dependency needs are a hallmark feature of dependent personality disorder (DPD), not schizotypal personality disorder. Clients with DPD exhibit excessive reliance on others for emotional support, difficulty making independent decisions, and fear of abandonment. In contrast, individuals with schizotypal personality disorder tend toward social isolation, interpersonal aloofness, and discomfort in close relationships, which is nearly the opposite of the dependent interpersonal style. Conflating these 2 disorders reflects a misclassification of personality disorder subtypes.
Choice C reason: Paranoid thoughts are a well-established and diagnostically significant characteristic of schizotypal personality disorder as defined by the DSM-5. During social situations, affected clients may experience suspiciousness and paranoid ideation, including transient, stress-related paranoid thoughts or ideas of reference — the belief that events in the environment have special personal significance. These cognitive distortions emerge in social contexts and contribute to the social withdrawal and discomfort that characterize the disorder. This is distinct from frank psychosis, as the paranoid thoughts in schizotypal personality disorder are generally not of delusional intensity.
Choice D reason: Perfectionism is a core feature of obsessive-compulsive personality disorder (OCPD), which is characterized by a pervasive preoccupation with orderliness, perfectionism, and mental and interpersonal control. OCPD is categorized under Cluster C personality disorders, whereas schizotypal personality disorder falls within Cluster A. The clinical features of schizotypal personality disorder center on odd beliefs, magical thinking, unusual perceptual experiences, social anxiety, and paranoia, not perfectionism or need for control. Attributing perfectionism to schizotypal personality disorder conflates 2 diagnostically distinct conditions.
Correct Answer is B
Explanation
Choice A reason: Attempting to convince the client that their current physical appearance is normal is a non-therapeutic and clinically ineffective response. Body dysmorphic disorder (BDD) involves a distorted cognitive perception of one's own appearance that is resistant to external reassurance, logical argumentation, or evidence to the contrary. The preoccupation in BDD is neurobiologically driven, involving dysfunction in visual processing areas and obsessive-compulsive neural circuitry. Simply asserting that the client looks normal will not alter the underlying perceptual distortion and may increase frustration and distrust of healthcare providers, while delaying appropriate psychiatric evaluation and intervention.
Choice B reason: Assessing the client for body dysmorphic disorder is the most clinically appropriate and evidence-based nursing response. The clinical scenario describes a pattern highly characteristic of BDD: persistent dissatisfaction with physical appearance following multiple cosmetic procedures, preoccupation with perceived flaws that are either minimal or not visible to others, and a compulsive desire for additional corrective surgeries. BDD is classified in the DSM-5 under obsessive-compulsive and related disorders and is associated with a compulsive pattern of seeking surgical and cosmetic procedures. Nurses and healthcare providers must screen for BDD before additional procedures are pursued, as surgery does not resolve the underlying disorder and may worsen the clinical picture.
Choice C reason: Explaining to the client that no further change is possible is factually inaccurate, potentially deceptive, and does not address the underlying psychiatric concern. Further cosmetic surgery is physically possible, and informing the client otherwise would constitute a lack of informed consent and honest communication. More importantly, this response fails to recognize or address the possibility that the client's repeated dissatisfaction with surgical outcomes may reflect a psychiatric disorder requiring assessment and treatment rather than a surgical problem requiring additional intervention. This response therefore both misleads the client and misses a critical clinical opportunity.
Choice D reason: Referring the client to another cosmetic surgeon without first assessing for body dysmorphic disorder would potentially facilitate a pattern of surgical seeking that is harmful to the client and ethically problematic. Individuals with BDD who undergo cosmetic surgery typically do not experience sustained satisfaction with outcomes and frequently present for additional procedures with ongoing or heightened preoccupation with perceived flaws. Research indicates that surgical intervention does not improve BDD symptomatology and may worsen the obsessive preoccupation and functional impairment. The appropriate clinical response before any surgical referral is comprehensive psychiatric assessment, including screening for BDD and other comorbid conditions such as major depressive disorder and OCD.
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