A person was online continuously for over 24 hours, posting rhymes on
official government websites and inviting politicians to join social
networks. The person has not slept or eaten for 3 days. What features of
mania are evident?
a.
Increased muscle tension and anxiety
c.
Poor judgment and hyperactivity
b.
Vegetative signs and poor grooming
d.
Cognitive deficits and paranoia
ANS: C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes
on government websites) are characteristic of manic episodes. The
distracters do not specifically apply to mania.
,A patient diagnosed with bipolar disorder is dressed in a red leotard and
bright scarves. The patient twirls and shadow boxes. The patient says gaily,
"Do you like my scarves? Here; they are my gift to you." How should the
nurse document the patient's mood?
a.
Euphoric
c.
Suspicious
b.
Irritable
d.
Confident
ANS: A
The patient has demonstrated clang associations and pleasant, happy
behavior. Excessive happiness indicates euphoria. Irritability, belligerence,
excessive happiness, and confidence are not the best terms for the patient's
mood. Suspiciousness is not evident
,A person was directing traffic on a busy street, rapidly shouting, "To work,
you jerk, for perks" and making obscene gestures at cars. The person has
not slept or eaten for 3 days. Which assessment findings will have priority
concern for this patient's plan of care?
a.
Insulting, aggressive behavior
b.
Pressured speech and grandiosity
c.
Hyperactivity; not eating and sleeping
d.
Poor concentration and decision making
ANS: C
Hyperactivity, poor nutrition, hydration, and not sleeping take priority in
terms of the needs listed above because they threaten the physical integrity
of the patient. The other behaviors are less threatening to the patient's life.
A patient diagnosed with acute mania has distributed pamphlets about a new
business venture on a street corner for 2 days. Which nursing diagnosis has
priority?
a.
Risk for injury
b.
Ineffective coping
c.
Impaired social interaction
d.
Ineffective therapeutic regimen management
ANS: A
Although each of the nursing diagnoses listed is appropriate for a patient
having a manic episode, the priority lies with the patient's physiological
safety. Hyperactivity and poor judgment put the patient at risk for injury.
, A patient diagnosed with bipolar disorder becomes hyperactive after
discontinuing lithium. The patient threatens to hit another patient. Which
comment by the nurse is appropriate?
a.
"Stop that! No one did anything to provoke an attack by you."
b.
"If you do that one more time, you will be secluded immediately."
c.
"Do not hit anyone. If you are unable to control yourself, we will help you."
d.
"You know we will not let you hit anyone. Why do you continue this
behavior?"
ANS: C
When the patient is unable to control his or her behavior and violates or
threatens to violate the rights of others, limits must be set in an effort to de-
escalate the situation. Limits should be set in simple, concrete terms. The
incorrect responses do not offer appropriate assistance to the patient,
threaten the patient with seclusion as punishment, and ask a rhetorical
question
official government websites and inviting politicians to join social
networks. The person has not slept or eaten for 3 days. What features of
mania are evident?
a.
Increased muscle tension and anxiety
c.
Poor judgment and hyperactivity
b.
Vegetative signs and poor grooming
d.
Cognitive deficits and paranoia
ANS: C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes
on government websites) are characteristic of manic episodes. The
distracters do not specifically apply to mania.
,A patient diagnosed with bipolar disorder is dressed in a red leotard and
bright scarves. The patient twirls and shadow boxes. The patient says gaily,
"Do you like my scarves? Here; they are my gift to you." How should the
nurse document the patient's mood?
a.
Euphoric
c.
Suspicious
b.
Irritable
d.
Confident
ANS: A
The patient has demonstrated clang associations and pleasant, happy
behavior. Excessive happiness indicates euphoria. Irritability, belligerence,
excessive happiness, and confidence are not the best terms for the patient's
mood. Suspiciousness is not evident
,A person was directing traffic on a busy street, rapidly shouting, "To work,
you jerk, for perks" and making obscene gestures at cars. The person has
not slept or eaten for 3 days. Which assessment findings will have priority
concern for this patient's plan of care?
a.
Insulting, aggressive behavior
b.
Pressured speech and grandiosity
c.
Hyperactivity; not eating and sleeping
d.
Poor concentration and decision making
ANS: C
Hyperactivity, poor nutrition, hydration, and not sleeping take priority in
terms of the needs listed above because they threaten the physical integrity
of the patient. The other behaviors are less threatening to the patient's life.
A patient diagnosed with acute mania has distributed pamphlets about a new
business venture on a street corner for 2 days. Which nursing diagnosis has
priority?
a.
Risk for injury
b.
Ineffective coping
c.
Impaired social interaction
d.
Ineffective therapeutic regimen management
ANS: A
Although each of the nursing diagnoses listed is appropriate for a patient
having a manic episode, the priority lies with the patient's physiological
safety. Hyperactivity and poor judgment put the patient at risk for injury.
, A patient diagnosed with bipolar disorder becomes hyperactive after
discontinuing lithium. The patient threatens to hit another patient. Which
comment by the nurse is appropriate?
a.
"Stop that! No one did anything to provoke an attack by you."
b.
"If you do that one more time, you will be secluded immediately."
c.
"Do not hit anyone. If you are unable to control yourself, we will help you."
d.
"You know we will not let you hit anyone. Why do you continue this
behavior?"
ANS: C
When the patient is unable to control his or her behavior and violates or
threatens to violate the rights of others, limits must be set in an effort to de-
escalate the situation. Limits should be set in simple, concrete terms. The
incorrect responses do not offer appropriate assistance to the patient,
threaten the patient with seclusion as punishment, and ask a rhetorical
question
