A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following?

A. Providing a flexible activity schedule allows the client to engage in activities that match their energy level and interests, promoting a sense of control and reducing agitation during acute

mania.

B. High-calorie nutritional supplements are not typically indicated solely based on the diagnosis of acute mania. Nutritional needs should be assessed, but providing high-calorie supplements

may not address the underlying issues associated with mania.

C. Allowing the client to eat meals alone in her room may not be safe or therapeutic during acute mania, as supervision during meals can ensure adequate nutrition and prevent potential harm or

inappropriate behaviors.

D. While promoting independence is important, allowing the client to choose her clothes independently may not be appropriate during acute mania, as it could result in wearing

inappropriate attire or exacerbate impulsivity.

- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.