A nurse is assessing a patient diagnosed with bipolar disorder who is in the manic phase. The patient is engaging in impulsive behavior, such as excessive spending. What is the priority nursing intervention?

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Question 1 of 5

A nurse is assessing a patient diagnosed with bipolar disorder who is in the manic phase. The patient is engaging in impulsive behavior, such as excessive spending. What is the priority nursing intervention?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient is exhibiting rapid speech, impulsive behavior, and an inflated sense of self-importance. What is the priority nursing intervention?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

A patient is brought to the Emergency Department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are pulse (P) 72 and respiration (R) 16. After being informed surgery is required for the broken leg, which vital sign readings would be expected?

Correct Answer: D

Rationale: The patient would experience stress associated with anticipation of surgery. In times of stress, the sympathetic nervous system takes over (fight or flight response) and sends signals to the adrenal glands, thereby releasing norepinephrine. The circulating norepinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs.

Question 4 of 5

A patient fearfully runs from chair to chair crying, 'They're coming! They're coming!' The patient does not follow the staff's directions or respond to verbal interventions. The initial nursing intervention of highest priority is to

Correct Answer: A

Rationale: Safety is of highest priority because the patient experiencing panic is at high risk for self-injury related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts. Offering an outlet for the patient's energy can occur when the current panic level subsides. Respecting the patient's personal space is a lower priority than safety. Clarification of feelings cannot take place until the level of anxiety is lowered.

Question 5 of 5

A patient tells a nurse, 'My best friend is a perfect person. She is kind, considerate, good-looking, and successful with every task. I could have been like her if I had the opportunities, luck, and money she's had.' This patient is demonstrating

Correct Answer: C

Rationale: Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller as well as the listener. Denial is an unconscious process that would call for the nurse to ignore the existence of the situation. Projection operates unconsciously and would result in blaming behavior. Compensation would result in the nurse unconsciously attempting to make up for a perceived weakness by emphasizing a strong point.

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