The emergency department (ED) is calling to report on a patient who will be admitted to your acute psychiatric unit. He has a history of bipolar disorder and was in an altercation that resulted in the death of another. He has contusions, abrasions, and minor lacerations. What is the priority question that you should ask?
“When will the patient be transferred?”
“Will a police officer be with him while he is on the unit?”
“Why isn’t the patient being admitted to the trauma unit?”
“What is the patient’s current mood and behavior?”
The Correct Answer is D
Acute mania in bipolar disorder can present with extreme agitation, impulsivity, and poor judgment, often escalating to aggressive or dangerous behavior. When admitting a client with recent violent involvement, the priority is to assess current mental status, including mood, behavior, and risk factors such as psychosis, suicidality, or homicidality. This guides immediate safety planning, medication needs, and level of observation. Physical injuries are secondary to psychiatric stabilization in this context, especially when the client is medically cleared.
Rationale for correct answer
4. Determining the client’s current mood and behavioral presentation is essential for psychiatric triage. It informs risk assessment, safety measures, and initial treatment planning, especially in the context of recent violence and bipolar history.
Rationale for incorrect answers
1. While transfer timing is operationally relevant, it does not address clinical urgency. Psychiatric units must first prepare for the client’s behavioral presentation and safety needs.
2. Police presence may be necessary depending on legal status, but asking this first overlooks clinical priorities. Risk assessment should precede logistical or custodial concerns.
3. The client’s physical injuries are minor and medically cleared, making psychiatric admission appropriate. Questioning trauma unit placement diverts focus from psychiatric stabilization.
Take Home Points
- Psychiatric triage prioritizes mental status and behavioral risk over logistical or custodial details.
- Acute mania may involve aggression, requiring immediate assessment of mood and safety risk.
- Physical injuries are managed medically before psychiatric admission; they do not override psychiatric needs.
- Understanding current behavior guides observation level, medication initiation, and staff safety planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Manic episodes in bipolar I disorder are characterized by elevated mood, hyperactivity, and impaired judgment, often resulting in risk-taking behaviors and physical exhaustion. Clients may exhibit pressured speech, pacing, and agitation, which significantly increase the risk of injury due to falls, collisions, or physical depletion. The priority in acute mania is to ensure safety, as the combination of psychomotor agitation and poor insight can lead to accidental harm or collapse from exhaustion. Nutritional and sleep deficits are important but secondary to immediate physical risk.
Rationale for correct answer
2. Margaret’s extreme hyperactivity and agitation place her at high risk for physical harm. Her inability to rest, combined with poor nutritional intake, increases the likelihood of injury from collapse, falls, or overexertion.
Rationale for incorrect answers
1. While Margaret’s poor intake is concerning, nutrition is not the most immediate threat. The physical consequences of hyperactivity, such as collapse or injury, take precedence in acute care.
3. Sleep disturbance is a hallmark of mania, but agitation and hyperactivity pose more immediate safety risks. Sleep can be addressed once Margaret is stabilized and safe.
4. Denial of illness is common in bipolar disorder, but coping strategies are not the priority during acute manic episodes. Immediate physiological safety concerns override psychosocial considerations.
Take Home Points
- In acute mania, physical safety risks due to hyperactivity and exhaustion are the top nursing priority.
- Nutritional and sleep deficits are important but secondary to injury prevention during manic episodes.
- Bipolar clients often lack insight into their condition, requiring structured interventions to ensure safety.
- Nursing diagnoses must prioritize physiological needs first, especially when behaviors threaten immediate harm.
Correct Answer is C
Explanation
Manic episodes in bipolar I disorder are marked by elevated mood, hyperactivity, and reduced need for sleep, often leading to poor nutritional intake and weight loss. Clients may be too distracted or restless to sit for meals, and their impulsivity can interfere with structured routines. Nutritional strategies must accommodate their erratic behavior while ensuring caloric sufficiency. High-calorie, nutrient-dense finger foods are ideal because they can be consumed quickly and frequently, even during periods of excessive movement or agitation.
Rationale for correct answer
3. Providing finger foods allows Beldine to maintain her hyperactive behavior while still consuming calories. These foods are portable, easy to eat, and can be offered frequently, supporting nutritional intake without requiring her to sit still.
Rationale for incorrect answers
1. Sitting with Beldine may not be effective due to her restlessness. She may resist structured meal times or leave the table prematurely, making this approach impractical during a manic phase.
2. While familiar foods may be comforting, relying on a family member to bring meals does not address the need for accessibility and caloric density. It also lacks consistency and clinical oversight.
4. Room restriction is punitive and may escalate agitation or noncompliance. It does not address the underlying issue of poor intake and may worsen behavioral symptoms during mania.
Take Home Points
- Clients in manic episodes often require flexible, high-calorie nutrition strategies due to hyperactivity and distractibility.
- Finger foods and snacks are more effective than structured meals for promoting intake during mania.
- Punitive measures like room restriction are contraindicated and may exacerbate agitation or noncompliance.
- Nutritional interventions should be tailored to behavioral presentation, especially in psychiatric conditions with fluctuating energy and attention.
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