A patient with bipolar disorder displays symptoms of labile mood and euphoria. What would be the most appropriate nursing action?
Encourage the patient to rest and hydrate adequately.
Provide concise and calm communication while setting firm limits.
Transfer the patient to a quiet care setting with minimal stimuli.
Reassess the patient's symptoms in 24 hours to see if they diminish.
The Correct Answer is B
Choice A reason: While physical needs like hydration and rest are critical in mania, they are often difficult to achieve without first managing the patient's behavioral output. Encouragement alone is frequently ineffective for a euphoric or labile patient whose racing thoughts and hyperactivity prevent them from recognizing the physical necessity of fluid intake or sleep.
Choice B reason: For a client experiencing euphoria and lability, the nurse must act as an external governor of behavior. Concise, calm communication prevents overstimulation and provides clear expectations. Setting firm limits is essential to maintain safety and therapeutic boundaries, as manic patients often display intrusive behavior, poor judgment, and impaired impulse control.
Choice C reason: Reducing environmental stimuli is a supportive intervention, but "transferring" a patient to a different setting may not always be feasible or address the immediate behavioral challenge. Environmental management is a secondary step; the primary nursing action involves the direct interpersonal approach and the establishment of a safe, structured behavioral framework.
Choice D reason: Delaying intervention for 24 hours is inappropriate and potentially dangerous. Symptoms of acute mania or hypomania can escalate rapidly, leading to exhaustion, physical injury, or social consequences. In a psychiatric setting, changes in mood and behavior require immediate clinical assessment and active management to ensure the safety of the milieu.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Risperidone is an atypical antipsychotic that functions as a dopamine D2 and serotonin 5-HT2A receptor antagonist. By modulating these neurotransmitter pathways, it effectively diminishes positive symptoms of schizophrenia, such as auditory hallucinations and delusional paranoia, which are the primary therapeutic targets for achieving clinical stabilization and safety.
Choice B reason: Significant weight loss is not a desired therapeutic outcome of risperidone; in fact, the medication is frequently associated with metabolic side effects, including significant weight gain, hyperlipidemia, and increased risk of type 2 diabetes. Monitoring metabolic parameters is a standard nursing intervention during treatment with atypical antipsychotics.
Choice C reason: While risperidone may have some sedative properties that could incidentally help with sleep, the absence of a need for sleep medication is not the specific clinical indicator used to determine if the antipsychotic is successfully treating the underlying primary symptoms of the client's schizophrenic disorder.
Choice D reason: Increased energy and hyperactivity are not desired outcomes and could actually indicate a worsening of symptoms or the development of adverse effects like akathisia. The goal of risperidone is to achieve behavioral stability and symptom reduction rather than inducing a state of heightened psychomotor activity or agitation.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: The client's blood pressure is not identified as a concerning finding in the provided nursing notes. While monitoring vitals is standard practice, there is no evidence of autonomic instability or hypertensive crisis that would take priority over the acute psychiatric symptoms the client is currently exhibiting.
Choice B reason: Hallucinations, specifically the command hallucinations mentioned where voices are "telling me I need to save the world," require immediate follow-up. Command hallucinations significantly increase the risk of unpredictable or dangerous behavior, as the client may feel compelled to act on these internal stimuli to fulfill a perceived mission.
Choice C reason: The client's report of insomnia ("I can't sleep") is a critical finding because sleep deprivation is a powerful trigger for the exacerbation of psychotic symptoms. In schizophrenia, a lack of restorative sleep can lead to a rapid decline in reality testing and an increase in the intensity of both hallucinations and delusions.
Choice D reason: The client is exhibiting clear delusions, such as believing they "need to save the world" and perceiving a man in the corner who is going to hurt them. These fixed false beliefs indicate an acute relapse of psychosis due to medication non-adherence and require immediate intervention to ensure the safety of the client.
Choice E reason: While the client only consumed 50% of their meal, appetite changes are less critical than the active positive symptoms of psychosis. Nutritional intake should be monitored over time, but in the context of an acute behavioral crisis with hallucinations, it is not one of the top three priorities for immediate follow-up.
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