A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply).
Social isolation
Impaired mood regulation
Imbalanced nutrition: more than body requirements
Chronic confusion
Sleep deprivation
Correct Answer : B,E
Rationale:
A. Social isolation is more typical in depression or withdrawal, not acute mania, where patients are often excessively social or intrusive.
B. Impaired mood regulation is characteristic of mania, involving mood swings, irritability, and poor impulse control.
C. Imbalanced nutrition: more than body requirements is unlikely during mania; patients often have decreased appetite.
D. Chronic confusion is not typical in acute mania; cognitive impairment may be present but is usually not chronic.
E. Sleep deprivation is common in manic episodes due to decreased need for sleep and hyperactivity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Shortness of breath and chronic cough are not typical early signs of lithium toxicity; these suggest possible respiratory or cardiac issues unrelated to lithium.
B. Early signs of lithium toxicity include gastrointestinal upset (nausea, diarrhea) and neuromuscular effects such as weakness.
C. ECG changes and chest pain can occur with severe toxicity, but they are not the most common initial symptoms.
D. Thirst may be a side effect of lithium due to nephrogenic diabetes insipidus, and nystagmus can occur in severe neurotoxicity, but these are not the classic early warning signs.
Correct Answer is C
Explanation
Rationale:
A. Suggesting it is unusual for the provider to continue lithium could undermine trust in the treatment plan and is inaccurate.
B. Lithium is typically continued long-term or indefinitely to prevent relapse, not just for 6 months.
C. Continuing daily lithium helps maintain mood stability and significantly reduces the risk of relapse in bipolar disorder, even when the patient feels well.
D. Stopping lithium after only 1 month of stability greatly increases the likelihood of recurrence of manic or depressive episodes.
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