A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?

Choice A reason: The first priority is to reduce environmental stimuli. Clients in manic states are highly sensitive to stimulation, which can worsen agitation and distractibility. A calm, low-stimulation environment helps stabilize behavior.

Choice B reason: Feedback about behavior may be helpful later, but in acute mania, the client’s ability to process feedback is impaired. Immediate environmental control is more effective.

Choice C reason: Explaining rules and policies is important, but during acute mania, the client cannot focus or retain complex information. This intervention is not appropriate as the first step.

Choice D reason: Introducing the client to staff increases stimulation and may worsen agitation. This should be delayed until the client is calmer.

Choice A reason:Withdrawal dependence refers to the physical and psychological symptoms experienced when alcohol use is stopped. This is not what the client is describing, as they are talking about needing more alcohol to achieve the same effect.

Choice B reason:This is correct because tolerance occurs when the body adapts to repeated exposure to alcohol, requiring larger amounts to achieve the same pleasurable effects. The client’s progression from one to two drinks to six drinks per episode clearly demonstrates tolerance.

Choice C reason:Intoxication refers to the immediate effects of alcohol consumption, such as impaired judgment, coordination, and mood changes. It does not explain the need for increasing amounts over time.

Choice D reason:Physical dependence involves experiencing withdrawal symptoms when alcohol is not consumed. The client’s statement does not describe withdrawal but rather the need for more alcohol to feel the same effect, which is tolerance.