Author Question: An adult male client has been admitted to a psychiatricmental health facility in a manic state. His ... (Read 72 times)

wrbasek0 · **on:** Jul 19, 2018

An adult male client has been admitted to a psychiatricmental health facility in a manic state. His wife accompanies him to the facility and informs you that he has been in a manic state for the past 2 weeks.

She states that he has not slept for the past 2 days and that he has not eaten anything for at least 3 days. Which of the following would be the highest priority nursing diagnosis for this client?
A) Ineffective Health Maintenance
B) Ineffective Coping
C) Risk for Imbalanced Nutrition
D) Risk for Suicide

Question 2

After observing a client with bipolar disorder on the mental health unit, the nurse determines that the client is at an acute risk for violence. Which of the following would be the most appropriate intervention?

A) Ask the client to sit alone and write a letter.
B) Restrict the client to his room until he calms down.
C) Encourage him to participate in an activity with other clients.
D) Tell the client that if he is violent, he will be sent home.

Liamb2179 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

Ans: C
Feedback:
A primary concern for clients with bipolar disorders is physiological integrity and function. Mania causes hyperactivity, resulting in an inability to sit still for the time needed to eat a meal. Clients with mania often neglect nutritional and fluid needs. While all listed nursing diagnoses are appropriate for the patient, restoring nutritional balance is the highest priority.

Answer to Question 2

Ans: B
Feedback:
If clients are determined to be at risk for violence, establishing geographic boundaries, such as room or half-hall restriction, is part of ongoing monitoring. Other environmental approaches include reducing stimuli and opportunities for interaction with other clients. Nurses remove all dangerous items from client rooms and monitor closely for use of any dangerous items. A pen or pencil that is used to write a letter can be a dangerous object.