A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior?
A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric."
B. "Mood euthymic. Exhibiting magical thinking. Restless."
C. "Mood labile. Exhibiting delusions of reference. Hyperactive."
D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."
ANS: D
The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.
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