A patient with bipolar disorder is hyperactive after discontinuing lithium and has not slept for 3 days. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
a. "Stop that! No one did anything to provoke an attack by you."
b. "If you do that one more time, you will be secluded immediately."
c. "Do not hit anyone. If you are unable to control yourself, we will help you."
d. "You know we will not let you hit anyone. Why do you continue this behavior?"
ANS: C
When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The first response does not offer appropriate assistance to the patient. The second response threatens the patient with seclusion as punishment. The fourth response asks a rhetorical question.
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