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
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.
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