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8/10/24, 7:02 AM Combo with CH. 14 REVIEW mental health Flashcards | QuizletCombo with CH. 14 REVIEW mental health
Jeremiah
Terms in this set (26)
Chapter 14: Bipolar Disorders Chapter 14: Bipolar Disorders
Answer Key - Chapter Review Answers and Answer Key - Chapter Review Answers and Rationales
Rationales
ANS: 1
Rationale: The immediate safety of the patient and other patients on the unit is the
priority. Limits regarding patient-to-patient contact and relations should be
1. Which behavior exhibited by a patient with
communicated and behavior should be monitored. While excessive spending of money
mania should the nurse choose to address
is commonly found in mania, it is not an immediate safety issue. "Being at one with the
first?
world" may be part of a delusional (false thoughts) system that commonly happens
1. Indiscriminate sexual relations
during mania. Delusions should be monitored, but this one does not sound dangerous
2. Excessive spending of money
and in need of any particular action. Flight of ideas, or jumping from topic to topic, is
3. Declaration of "being at one with the
also a common symptom in mania. While they may make communication difficult, they
world"
are not a priority concern.
4. Demonstration of flight of ideas
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX Client Needs: Psychosocial Integrity
2. The nurse is caring for a patient ANS: 1
experiencing mania. Which is the most Rationale: Patients experiencing mania have the ability to staff split, or divide the staff
appropriate nursing into "good guys" or "bad guys." Providing consistency among all staff members is
intervention? imperative. Limits must be set and carried out by all staff members if the plan of care is
1. Provide consistency among staff members to be effective. Because the
when working with the patient. nurse cannot control the patient's emotions, the preferred approach is to establish and
2. Negotiate limits so the patient has a voice maintain limits for the duration of admission.
in the plan of care. Nursing Process: Implementation
3. Allow only certain staff members to Cognitive Level: Analysis
interact with the patient. NCLEX Client Needs: Psychosocial Integrity
4. Attempt to control the patient's emotions.
3. The nurse is planning care for a patient ANS: 1
experiencing the acute phase of mania. Rationale: Safety is always the highest priority in planning care. All other interventions
Which is the priority intervention? may be included in the plan of care, but the priority is to keep the patient safe.
1. Prevent injury. Nursing Process: Planning
2. Maintain stable cardiac status. Cognitive Level: Application
3. Get the patient to demonstrate thought NCLEX Client Needs: Physiological Integrity: Reduction of Risk Potential
self-control.
4. Ensure that the patient gets sufficient
sleep and rest.
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