d. avoid eating aged cheese, processed meats, and red wine. ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 13-53 (Box 13-1) TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity
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21. Which nursing diagnosis would most likely apply to a patient diagnosed with major depressive disorder as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping
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ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.
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PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 13-12, 19, 44 (Table 13-2) | Page 13-14; also incorporates content from Chapter 14 TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Psychosocial Integrity
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22. Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream
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ANS: C These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive patient could eat while in motion. The foods in the incorrect options cannot be eaten without utensils.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 13-18, 19, 46 (Table 13-3) | Page 13-19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
23. Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.
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