An inappropriately dressed patient has not slept for 3 days while making excessive, ex-pensive long-distance phone calls. When the patient can be heard singing loudly in the examining room, the nurse makes initial plans to focus on:
a. Assessing needs for food, liquids, and rest
b. Setting strict limits on dress and behavior
c. Conducting an in-depth suicide assessment
d. Obtaining a complete psychosocial assessment
ANS: A
Patients with mania frequently ignore their basic physiologic needs, as evidenced by not sleeping for 3 days, thus making these assessments the priority. Limits, although appropriate to consider, are not the priority. The manic state precludes a thorough assessment initially. Suicide assessment is not a priority at this time but reckless behavior could result in personal injury.
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