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The nurse continues to care for the client.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is most likely experiencing

as evidenced by the client's.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Mania is characterized by an abnormally elevated, expansive, or irritable mood accompanied by increased energy or activity. This client’s obsessive cleaning, excessive spending, sleeplessness, pressured speech, and overly joyous behavior strongly support a manic episode.
  • Euphoric mood refers to an exaggerated feeling of well-being or elation not consistent with the client's circumstances. It often presents in mania alongside impulsivity and grandiosity, such as the client’s obsession with hosting parties and giving away money without regard for consequences.

Rationale for Incorrect Choices:

  • Delirium: Typically presents with fluctuating consciousness, acute onset confusion, and disorganized thinking often due to a medical cause. The client is alert and oriented to person and time, which is inconsistent with the inattention and acute cognitive changes of delirium.
  • Catatonia: Characterized by motor immobility, extreme negativism, mutism, or stupor. The client displays hyperactivity and pressured speech, which are the opposite of the psychomotor retardation seen in catatonia.
  • Panic disorder: Involves sudden onset of intense fear with physical symptoms such as palpitations, chest pain, or shortness of breath. It lacks the prolonged mood elevation, impulsivity, and grandiosity observed in this case.
  • Major depressive disorder: Presents with persistent sadness, fatigue, anhedonia, and social withdrawal. The client’s symptoms of increased activity, grandiosity, and reduced need for sleep do not align with depression.
  • Alogia: Refers to poverty of speech or reduced speech output, often associated with schizophrenia or severe depression. This contrasts with the client’s pressured and excessive speech.
  • Magical thinking: Involves believing one’s thoughts can influence the physical world, often seen in psychotic disorders or schizotypal personality disorder. The client describes hallucinations, but no evidence of magical thinking is present.
  • Hypervigilance: Describes excessive alertness or scanning for threats, commonly associated with anxiety or PTSD. The client’s symptoms point to elevated mood and disinhibition, not heightened fear or threat perception.
  • Anhedonia: A core symptom of depression, characterized by a loss of interest or pleasure in activities. The client’s increased goal-directed activity and enjoyment in planning events contradict this finding.


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Related Questions

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

• Compartment syndrome: Occurs when pressure within a closed muscle compartment compromises circulation and tissue function. The client presents with classic signs: pain out of proportion, pallor (cool foot), pulselessness (non-palpable pulses), paresthesia (numbness), and paralysis (inability to move foot/toes) which are hallmark signs of compromised perfusion.

  • Osteomyelitis: The presence of drainage from the splint site, increasing temperature, and markedly elevated WBC count (from 14,000 to 28,000/mm³) strongly suggest developing bone infection. The client’s open fracture and internal fixation increase susceptibility, especially with new signs of systemic infection and localized inflammation at the injury site.

Rationale for Incorrect Choices:

• Deep vein thrombosis (DVT): While trauma and immobility increase DVT risk, there is no evidence of unilateral leg swelling, calf tenderness, or redness. The primary concern here is neurovascular compromise, not venous thromboembolism, and the symptoms point more urgently to compartment syndrome and infection.

• Fat embolism syndrome: Fat embolism is a risk with long bone fractures, typically presenting within 24–72 hours with respiratory distress, hypoxia, confusion, and a petechial rash. This client is alert and not in respiratory distress, with normal oxygen saturations and no mental status changes, making fat embolism less likely at this stage.

Correct Answer is C

Explanation

A. Polyuria: Polyuria results from hyperglycemia, where excess glucose in the bloodstream leads to osmotic diuresis. This causes the kidneys to excrete more water, increasing urination frequency. It is not a feature of hypoglycemia.
B. Fruity breath: Fruity-scented breath is due to ketone buildup in diabetic ketoacidosis, a complication of prolonged hyperglycemia. It signals metabolic acidosis rather than low blood sugar levels.
C. Diaphoresis: Diaphoresis occurs during hypoglycemia as the body releases epinephrine in response to falling glucose. This triggers sweating, tremors, and palpitations as part of the autonomic response.
D. Polyphagia: Polyphagia is a symptom of hyperglycemia, where cells are starved of glucose despite its presence in the blood. This leads to increased hunger, not typically seen in acute hypoglycemia.

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