A 38-year-old married mother of two was admitted to the ...

[ss2343]

A 38-year-old married mother of two was admitted to the psychiatric unit. Recently she has spent 10,000 on new furniture, made excessive long-distance phone calls, and has not slept for 3 days.
 
  She is presently dressed in a green bathing suit and singing loudly in the examining room. The nurse would initially plan to focus on:
  1. Assessing needs for food, liquids, and rest
  2. Setting strict limits on dress and behavior
  3. Obtaining a complete psychosocial assessment
  4. Conducting an in-depth suicide assessment

Question 2

Two weeks after admission for a manic episode, a client and the nurse have had several sessions discussing medications. Which statement by the client would indicate the need for additional education regarding her lithium treatment regimen?
 
  1. I will drink 8 to 12 glasses of liquids daily.
  2. I will restrict my daily salt intake.
  3. I will take my medications with food.
  4. I will have my blood drawn on schedule.

[pallen55]

Answer to Question 1

ANS: 1
Clients with mania frequently ignore their basic physiologic needs, as evidenced by not sleeping for 3 days, thus making these assessments the priority. 2. Limits, while appropriate to consider, are not the priority. 3. The manic state precludes a thorough assessment initially. 4. Suicide as-sessment is not a priority at this time.

Answer to Question 2

ANS: 2
Clients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. 1. The client should have 2-3 liters of fluid daily. 3. Taking lithium with food minimizes gastro-intestinal side effects. 4. Regular monitoring of lithium levels is important to prevent toxicity.