Which initial nursing intervention should be planned for a newly admitted patient with acute mania?
a. Allow the patient to act out suppressed feelings because the environment is safe.
b. Provide verbal instructions to the patient to remain calm and cooperative.
c. Be accessible to set limits on the patient's behavior as necessary.
d. Restrain the patient to reduce hyperactivity and aggression.
C
This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. Patient will probably be unable to focus on instruction and comply. Seclusion or restraints are used only after other interventions have proved ineffective.
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a. "Help me understand how pain is affecting you right now." b. "I wish I could do more; is there anything I can get for you?" c. "You cannot have more pain medication for 3 hours." d. "Why do you think the medication is not helping your pain?"
A 13-year-old girl tells the nurse she is concerned because she has not had her first menstrual period. What is the best initial response from the nurse?
a. "Your hormone levels may be irregular." b. "Could you be pregnant?" c. "Age of first menstrual cycle varies." d. "Do not worry about it."
A client is unwilling to go out of the house for fear of "having to get on a elevator or be in small room." Because of this fear, the client remains home except when accompanied outside by the spouse. The nurse suspects that the client has:
A. Agoraphobia. B. Hematophobia. C. Claustrophobia. D. Hypochondriasis.
A patient is being seen in the clinic for insomnia. The nurse explains that the best diagnostic indicator of insomnia is:
A) the patient's report of insomnia. B) results of polysomnography. C) completing the Pittsburgh Sleep Quality Index. D) results of actigraphy.