Page 2261 - Saunders Comprehensive Review For NCLEX-RN

a. Assess and monitor whether the client
is a danger to self or others.
b. Assess for alcohol or substance
use/misuse.
c. Mood
d. Behavior
e. Speech (flight of ideas, tangential)
f. Cognitive functioning
g. Inflated self-regard (delusions of
grandeur)
h. Sleeping pattern
i. Impulse control
3. Interventions for mania (Box 65-6)
a. Remove hazardous objects from the
environment (this should be done for
all clients).
b. Assess the client closely for fatigue.
c. Provide frequent rest periods and
monitor the client’s sleep patterns; use
comfort measures to promote sleep.
d. Provide a private room if possible.
e. Encourage the client to ventilate
feelings.
f. Use calm, slow interactions.
g. Help the client focus on 1 topic during
the conversation.
h. Ignore or distract the client from
grandiose thinking; present reality to
the client.
i. Do not argue with the client.
j. Limit group activities and assess the
client’s tolerance level; solitary
activities may be necessary.
k. Provide high-calorie finger foods and
fluids.
l. Reduce environmental stimuli.
m. Set limits on inappropriate behaviors.
n. Provide physical activities and outlets
for tension.
o. Avoid competitive games.
p. Provide gross motor activities such as
walking.
q. Provide structured activities or one-to-
one activities with the nurse.
r. Provide simple and direct explanations
for routine procedures.
s. Supervise the administration of
medication.

2261