The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Choice A Reason:
Constant talking, also known as pressured speech, is a common symptom of mania in bipolar disorder. During a manic episode, individuals often experience a rapid flow of speech that is difficult to interrupt. This symptom is indicative of the heightened energy levels and racing thoughts associated with mania. Pressured speech can be overwhelming for both the individual and those around them, as it often includes rapid shifts in topics and an inability to focus on one subject.

Choice B Reason:
Expressing feelings of inferiority is more commonly associated with depressive episodes rather than manic episodes. During a depressive episode, individuals may experience low self-esteem, feelings of worthlessness, and a pervasive sense of sadness. These symptoms are in contrast to the elevated mood and increased self-confidence typically seen in mania.

Choice C Reason:
Memory loss is not a primary indicator of mania. While cognitive impairments can occur in bipolar disorder, they are not specific to manic episodes. Memory loss can be associated with various conditions, including depression, anxiety, and other neurological disorders. It is important to differentiate between symptoms specific to mania and those that may arise from other conditions.

Choice D Reason:
Sleeping over 10 hours a day is indicative of hypersomnia, which is more commonly seen in depressive episodes. During a manic episode, individuals typically experience a decreased need for sleep and may function on very little rest without feeling tired. The reduced need for sleep is a hallmark symptom of mania and helps distinguish it from depressive episodes.

Choice A Reason:
Suggesting the client make a list of things that make him angry can be a useful therapeutic activity, but it is not the priority action in a situation where the client is currently being aggressive. The immediate concern is to ensure the safety of the client and others. Once the situation is de-escalated, exploring triggers and coping strategies can be beneficial.

Choice B Reason:
Role modeling healthy ways to express anger is an important part of long-term therapeutic intervention, but it is not the priority when a client is actively aggressive. The nurse's immediate priority should be to assess the risk of harm and take steps to ensure safety. Role modeling can be incorporated into the care plan once the immediate threat is managed.

Choice C Reason:
Asking the client if he intends to harm others is the priority action. This assessment helps determine the level of risk and the necessary interventions to ensure safety. Understanding the client's intentions allows the nurse to take appropriate measures, such as initiating de-escalation techniques or seeking additional support. Safety is the primary concern in managing aggressive behavior.

Choice D Reason:
Assisting the client to explore techniques to reduce stress is a valuable intervention for managing aggression in the long term. However, it is not the immediate priority when the client is currently aggressive. The nurse must first ensure the safety of all individuals involved before focusing on stress reduction techniques.