A nurse is assisting in the care of a client who has bipolar disorder and is experiencing mania. Which of the following actions should the nurse take to promote a therapeutic environment?

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

A. Reaction formation is a defense mechanism where an individual expresses feelings or impulses that are the opposite of their anxiety-provoking unconscious feelings. For example, someone who harbors unconscious aggressive feelings might demonstrate exaggerated friendliness. However, this defense mechanism is more about behaviors and attitudes rather than physical manifestations.
B. Somatization is the conversion of psychological distress into physical symptoms. It involves experiencing physical symptoms, such as pain or illness, without a clear medical cause. This defense mechanism is common in individuals with anxiety disorders who may manifest their anxiety through physical complaints rather than acknowledging their emotional distress.
C. Sublimation involves channeling unacceptable impulses or emotions into socially acceptable behaviors. It does not typically involve physical manifestations but rather a redirection of emotions or impulses into constructive activities. For example, someone with aggressive impulses might channel them into sports or artistic pursuits.
D. Intellectualization is a defense mechanism where reasoning and logic are used to distance oneself from uncomfortable or threatening feelings. It involves focusing on facts and avoiding emotions associated with a situation. This mechanism is more cognitive and may involve discussing or analyzing anxiety-inducing situations in a detached, rational manner.