A nurse in a mental health clinic is assessing a client who has dependent personality disorder. Which of the following findings should the nurse expect?

Choice A reason: Sitting with the client during mealtimes is an essential intervention because clients with bipolar disorder, especially during manic episodes, often have poor appetite and difficulty focusing long enough to eat. Direct support ensures nutritional intake, prevents further weight loss, and provides structure. It also reduces the risk of malnutrition and dehydration, which are common complications in manic states.

Choice B reason: Turning on the television for the client is not therapeutic. Clients in manic episodes are easily overstimulated, and television can increase agitation, distractibility, and hyperactivity. Instead of calming the client, it may worsen confusion and disorientation. Therefore, this intervention is inappropriate.

Choice C reason: Removing sharp objects from the client’s room is a critical safety measure. Clients with bipolar disorder experiencing mania may act impulsively, and the risk of self-harm or accidental injury is high. Ensuring the environment is free of dangerous objects reduces the likelihood of harm and supports safe management of the client’s agitation.

Choice D reason: Observing the client every 15 minutes is necessary for safety monitoring. The client is hyperactive, confused, and disoriented, which increases the risk of injury, aggression, or unpredictable behavior. Frequent observation allows early detection of escalating agitation and ensures timely intervention. This is a standard safety protocol in acute psychiatric care.

Choice E reason: Providing a low-protein diet is not indicated. Clients with bipolar disorder do not require protein restriction; in fact, adequate protein intake is important for maintaining energy and nutritional balance. Restricting protein could worsen malnutrition and weight loss. This intervention is inappropriate.

Choice F reason: Offering the client physical activities is beneficial because it provides a safe outlet for excess energy during manic episodes. Structured physical activity helps reduce agitation, channel hyperactivity, and promote better sleep. It also decreases restlessness and supports overall emotional regulation. Activities should be simple, noncompetitive, and safe to avoid overstimulation.

Choice A reason: Offering the client a PRN dose of lorazepam is appropriate because benzodiazepines are often prescribed for acute agitation and anxiety. Administering medication can help de-escalate the situation, reduce the risk of violence, and restore calm. This intervention directly addresses the client’s agitation and promotes safety for both the client and others.

Choice B reason: Asking open-ended questions during an episode of acute agitation is not appropriate. Open-ended questions require thought and elaboration, which can increase frustration and escalate aggression. In crisis situations, communication should be simple, direct, and focused on safety rather than exploration.

Choice C reason: Standing directly in front of the client is unsafe because it places the nurse in a vulnerable position if the client becomes physically aggressive. The nurse should maintain a safe distance and stand at an angle to reduce the risk of harm.

Choice D reason: Moving others away from the client is correct because it protects the safety of the group. Removing potential targets of aggression reduces the risk of injury and helps de-escalate the environment. This is a critical safety measure in managing violent behavior.

Choice E reason: Speaking in an aggressive tone of voice is inappropriate because it escalates tension and may provoke further aggression. The nurse should use a calm, firm, and non-threatening tone to de-escalate the situation.