A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient exhibits impulsive behavior and makes rash decisions. What is the priority nursing intervention?

Correct Answer: B

Rationale: In caring for a patient diagnosed with bipolar disorder in the manic phase, the priority nursing intervention is to select option B, which is to set firm boundaries and limit the patient's ability to make impulsive decisions. This is crucial because individuals in the manic phase of bipolar disorder often lack the ability to control their impulses and may engage in risky behaviors that can be harmful to themselves or others. By setting firm boundaries, the nurse can help maintain a safe environment for the patient and prevent potential negative outcomes. Option A, encouraging the patient to express their feelings and engage in social activities, may not be the priority in this situation as the patient's impulsivity and risk-taking behavior need to be addressed first to ensure safety. Option C, providing medications to control symptoms, is important but may not address the immediate need to manage the impulsive behavior. Option D, offering reassurance and allowing the patient to make their own decisions, could potentially worsen the situation by enabling further impulsive behavior without appropriate limits. Educationally, understanding the priority interventions in managing patients with bipolar disorder is essential for nurses working in behavioral health settings. This scenario highlights the importance of safety and boundary-setting when caring for individuals experiencing manic episodes, emphasizing the need for proactive and structured interventions to promote patient well-being.

Correct Answer: B

Rationale: In this scenario, the most appropriate nursing diagnosis for a patient with generalized anxiety disorder who reports excessive worry about work, family, and health is option B) Anxiety. The rationale behind selecting "Anxiety" as the correct nursing diagnosis is that generalized anxiety disorder is characterized by excessive and uncontrollable worry about various aspects of life. Anxiety is a fundamental component of this disorder, and addressing it directly is crucial in providing effective nursing care. Option A) Ineffective coping may seem plausible, but it is not as specific to the primary symptom of anxiety that the patient is experiencing. While ineffective coping may be a secondary concern, the primary focus should be on addressing the anxiety itself. Option C) Disturbed thought processes is not the most appropriate nursing diagnosis for this patient as the primary issue lies in the emotional domain of anxiety rather than cognitive disturbances. Option D) Imbalanced nutrition: Less than body requirements is not relevant to the symptoms presented by the patient in the scenario and is not a priority compared to addressing the patient's anxiety. In an educational context, understanding the nuances of different nursing diagnoses is essential for providing accurate and effective care to patients. By selecting the most appropriate diagnosis, nurses can tailor their interventions to target the underlying issue, leading to improved patient outcomes and quality of care.

Correct Answer: D

Rationale: When the patient (primary source) is unable to provide information, secondary sources should be used, in this case, the family member. Later, more data may be obtained from other information sources familiar with the patient. An advanced practice nurse is not needed for this assessment; it is within the scope of practice of the staff nurse. Calling a mental health advocate is unnecessary.

Correct Answer: B

Rationale: In caring for a patient with schizophrenia exhibiting negative symptoms like lack of motivation and limited speech, providing the patient with a structured routine and encouraging participation in small tasks (Option B) is the most appropriate intervention. This approach helps establish predictability and consistency, which can be comforting and motivating for the patient. It also breaks tasks into manageable steps, facilitating engagement without overwhelming the patient. Option A is not the best choice as patients with negative symptoms may find social activities and discussing feelings challenging due to their limited speech and lack of motivation. Option C, allowing the patient to rest completely, may reinforce isolation and worsen symptoms. Option D, telling the patient to try harder, can be demotivating and increase feelings of frustration and inadequacy. In an educational context, understanding the nuances of symptom management in schizophrenia is crucial for nurses working in behavioral health. By choosing the most appropriate intervention based on the patient's symptoms, nurses can promote a therapeutic environment that supports the patient's well-being and recovery.

Correct Answer: D

Rationale: In this case, the nurse lacks information about what stressors the patient is coping with or about what coping skills are already possessed. Further assessment is indicated before potential solutions can be explored. Suggesting exploration of the stress facing the patient is the only option that involves further assessment rather than suggesting a particular intervention.