A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?
Have the patient sit in his room while you review all the rules of the unit.
Reinforce previously learned coping mechanisms to calm the patient down.
Place the patient in a room with another hyperactive patient.
Administer antipsychotic medication as ordered and as needed by the physician.
The Correct Answer is D
Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.
Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.
Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.
Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:Grandiosity refers to an exaggerated sense of one's importance, power, knowledge, or identity—even with little evidence to support this. In bipolar disorder, grandiosity can occur during both manic and hypomanic episodes. Individuals experiencing grandiosity may believe they have special powers, abilities, or are destined for greatness. This behavior aligns with the client's statement about revolutionizing the industry, which reflects an inflated sense of self-importance.
Choice B Reason:Flight of ideas is characterized by rapid, continuous, and often disjointed thoughts. It is a symptom commonly seen in manic episodes of bipolar disorder. However, the client's statement does not specifically indicate flight of ideas.
Choice C Reason:Confabulation refers to the production of fabricated or distorted memories or information. It is not directly related to the client's statement about revolutionizing the industry
Choice D Reason:Clang associations involve the use of rhyming or similar-sounding words without logical connections. While it is a symptom seen in some mental health conditions, it is not directly applicable to the client's behavior described in the question.
Correct Answer is C
Explanation
Choice A reason: Anginal pain typically does not worsen with deep inspiration; this is more characteristic of pleuritic chest pain.
Choice B reason: Anginal pain usually does not persist with rest and organic nitrates; these interventions are typically used to alleviate angina.
Choice C reason: Exertion and anxiety increase the heart's demand for oxygen, which can trigger anginal pain due to reduced blood flow in narrowed coronary arteries.
Choice D reason: Anginal pain typically lasts for a short time, usually less than 20 minutes. If the pain lasts longer, it may indicate a more serious condition like a myocardial infarction.
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