Ati nurs 541 mental health proctored exam(behavioral health)
A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
Explanation & Rationale
A. This statement is confrontational and asks why, which can escalate agitation rather than calm the patient. B. This response is clear, firm, and sets limits on unsafe behavior while offering support. It reassures the patient that the nurse will maintain safety, but in a therapeutic, non-punitive way. C. This is judgmental and blaming, which is not therapeutic and may increase hostility. D. Threatening seclusion immediately without first trying therapeutic limit-setting escalates fear and aggression. Seclusion is a last resort after other interventions fail.
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