The nurse continues to care for the client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is most likely experiencing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measure the tubing from the nose to the distal port: Proper measurement of the NG tube ensures correct placement into the stomach. The usual method involves measuring from the tip of the nose to the earlobe and then to the xiphoid process, not to the distal port of the tube, but this choice most closely aligns with verifying safe tube length.
B. Complete the feeding in 5 min: Administering a feeding too quickly can cause abdominal cramping, vomiting, or aspiration. Feedings should be given slowly, typically over 15 to 30 minutes, depending on the child's tolerance and the volume.
C. Warm the formula in the microwave: Microwaving formula can cause uneven heating and result in hot spots that may burn the child’s mouth or GI tract. Formula should be warmed by placing the container in warm water and testing the temperature before administration.
D. Position the child at a 10° to 20° angle after feeding: This angle is too low and increases the risk of aspiration. The child should remain at a 30° to 45° angle for at least 30 minutes after feeding to promote digestion and prevent reflux.
Correct Answer is A
Explanation
A. Orange slices: Vitamin C-rich foods like oranges significantly enhance the absorption of nonheme iron found in plant-based diets. This makes them an ideal recommendation for vegetarians needing increased iron intake.
B. Cheddar cheese: Dairy products contain calcium, which can actually inhibit iron absorption, making this an unhelpful choice for enhancing iron uptake.
C. Boiled eggs: While eggs contain some iron, they do not enhance the absorption of nonheme iron and may contain components that slightly interfere with its absorption.
D. Mixed nuts: Although they provide some nonheme iron, they do not improve its absorption. They lack vitamin C and are not effective enhancers on their own.
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