A nurse is caring for a patient diagnosed with bipolar disorder who is in the manic phase. The patient states, 'I don't need to sleep. I feel great!' Which of the following is the priority nursing diagnosis for this patient?

Correct Answer: B

Rationale: In this scenario, the priority nursing diagnosis for a patient with bipolar disorder in the manic phase stating "I don't need to sleep. I feel great!" is option B) Risk for injury related to impulsive and reckless behavior. This is the correct choice because during the manic phase, individuals often engage in risky behaviors due to their elevated mood and decreased impulse control. The patient's statement indicates a lack of recognition of the need for sleep, which can lead to increased impulsivity and potential harm. Option A is incorrect as disturbed sleep pattern, though important, is secondary to the immediate risk of injury. Option C is incorrect because while imbalanced nutrition may occur in bipolar disorder, the safety concern of impulsive behavior takes precedence. Option D is incorrect as ineffective coping is a concern, but the immediate risk of injury due to reckless behavior is the priority in this case. Educationally, understanding the hierarchy of nursing diagnoses in managing patients with bipolar disorder is crucial. Prioritizing safety concerns and addressing immediate risks is fundamental in providing effective care for individuals experiencing manic episodes. It is essential for nurses to recognize and respond to potential harm that may result from impulsive behaviors during the manic phase.

Correct Answer: D

Rationale: The nurse would place a priority on monitoring and reinforcing suicide self-restraint because it relates directly and immediately to patient safety. Patient safety is always a priority concern. The nurse should monitor and reinforce all patient attempts to control anxiety, improve sleep patterns, and develop self-esteem, while giving priority attention to suicide self-restraint.

Correct Answer: C

Rationale: In this scenario, the correct first priority action for the nurse is option C: Ensure the patient's safety by removing potential means of self-harm. This is the most critical action because it directly addresses the immediate threat to the patient's life. By removing potential means of self-harm, such as sharp objects or medications, the nurse can prevent the patient from acting on the voices instructing self-harm. Option A is incorrect as asking about suicidal thoughts and plans should follow ensuring immediate safety. Option B is also incorrect as encouraging the patient to talk about delusions and hallucinations, while important for assessment and therapeutic communication, is not the most urgent action in this situation. Option D is not the first priority because administering antipsychotic medication may take time to be effective and does not directly address the immediate safety concern. In an educational context, it is crucial for nurses to prioritize actions based on the level of risk to the patient's safety. Immediate interventions to ensure patient safety, such as removing potential means of harm, take precedence over other assessments or treatments in situations where a patient expresses intent to harm themselves. This prioritization is essential in providing effective and timely care to patients with mental health conditions like schizophrenia.

Correct Answer: B

Rationale: In this scenario, the most appropriate intervention is option B) Teach the patient relaxation techniques to help manage anxiety. Generalized anxiety disorder is characterized by excessive and uncontrollable worry about various aspects of life. Teaching the patient relaxation techniques such as deep breathing, progressive muscle relaxation, or mindfulness can help them cope with their anxiety symptoms effectively. Option A) Encouraging the patient to confront their anxieties head-on may exacerbate their anxiety and lead to increased distress. Patients with generalized anxiety disorder often find it challenging to confront their worries directly without proper coping mechanisms in place. Option C) Reassuring the patient that their worries are unfounded and unimportant may invalidate their feelings and experiences, potentially worsening the therapeutic relationship and diminishing the patient's trust in the nurse. Option D) Encouraging the patient to avoid stressful situations whenever possible is not a recommended approach as it promotes avoidance behavior, which can further reinforce anxiety in the long term. It is essential to empower patients with coping strategies rather than avoidance tactics. Educationally, it is crucial for nurses to understand the evidence-based interventions for managing generalized anxiety disorder. By teaching relaxation techniques, nurses empower patients to take an active role in managing their symptoms and promote self-care practices that can enhance their overall well-being. This rationale highlights the importance of individualized, patient-centered care in addressing mental health challenges like generalized anxiety disorder.

Correct Answer: A

Rationale: A patient has the right to know with whom the nurse will share information and that confidentiality will be protected. Although the relationship is primarily between the nurse and patient, other staff needs to know pertinent data. The other incorrect responses promote incomplete disclosure on the part of the patient, require daily renegotiation of an issue that should be resolved as the nurse-patient contract is established, and suggest mutual problem solving. The relationship must be patient centered. See relationship to audience response question.