A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client?
A. Ineffective individual coping R/T hospitalization AEB alcohol abuse
B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss
C. Risk for violence: directed toward others R/T agitation and hyperactivity
D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night
ANS: C
Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression.
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