# The nurse reviews the admission note for a client experiencing mania. Which findings require immediate follow-up? Highlight the behaviors that create an imminent risk of harm. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=494272&lang=en > language: en > subject: Mental Health Concepts > category: PSI ## Question The nurse reviews the admission note for a client experiencing mania. Which findings require immediate follow-up? Highlight the behaviors that create an imminent risk of harm. Nurses' Notes 2210: A client with bipolar I disorder is admitted during a manic episode. The client slept less than two hours nightly for three nights and remained continuously active. Speech is rapid, and the client changes topics before questions are completed. The client selected brightly colored clothing and several pieces of costume jewelry. The client announces, I will leave tonight and drive 120 miles per hour because my reflexes are perfect. The client walks rapidly in the hallway, redirects near the nurses' station, and maintains personal space when reminded. The client accepts a high-calorie sandwich and bottled water while continuing to move. After another client asks for quiet, the client lifts a chair and says it will be thrown if anyone interferes. The client describes plans for three new businesses and says every plan will succeed. A family member reports, the client can access a large savings account and plans to buy a sports car before morning. The client agrees to discuss prescribed medication in a quiet room with one staff member. The nurse moves other clients away, calls for assistance, reduces stimulation, and begins the facility's least-restrictive safety process. ## Explanation Severe sleep loss with escalating activity, dangerous driving intent, physical threats, and access to money for reckless purchases create immediate safety risks. Other manic symptoms also need treatment but are not equally imminent. ## In-depth explanation Quick answer Act immediately on three nights of almost no sleep with nonstop activity, the plan to drive at extreme speed, a raised chair with a threat toward another client, and access to large funds for an impulsive purchase. Why this is correct Mania can include decreased need for sleep, markedly increased activity, inflated power, and reckless behavior.[2] The selected cues go beyond diagnostic symptoms and show immediate danger to the client or others. Easy analogy or mental picture Picture an engine running with no brakes. Fast speech and bright clothing show the engine is revving; threats, dangerous driving, no restorative sleep, and uncontrolled spending show the brakes are failing. Memory hook No sleep, unsafe speed, threat, unrestricted spending: secure safety first. NCLEX decision rule In psychiatric priority questions, separate symptoms from immediate danger. Reduce stimulation, set clear limits, protect access to people and resources, and use the least restrictive safe intervention consistent with policy. Why the other choices are wrong Rapid speech, colorful clothing, expansive ideas, pacing without aggression, accepting food, and cooperative medication discussion support the diagnosis and ongoing plan. They do not independently show the same imminent harm.References - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]NIMH: Bipolar DisorderNational Institute of Mental Health ## Related questions - [A client hospitalized for depression says, "My family would be better off without me." Whi…](https://mymerci.kr/pages/nclex_q.php?qn_id=393687&lang=en) - [A client with schizophrenia says, "The voices are telling me to do something bad." Which r…](https://mymerci.kr/pages/nclex_q.php?qn_id=394025&lang=en) - [A client arrives with bruises at different stages of healing. 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