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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 ["A","C","E","F","G","J"]

Explanation

Rationale for Correct Findings:

  • WBC count 33,000/mm³: A significantly elevated white blood cell count strongly suggests a serious postpartum infection such as endometritis or sepsis, especially in a client with additional risk factors like cesarean birth and prolonged rupture of membranes.
  • Moderate amount of dark brown, foul-smelling lochia: Malodorous lochia is a hallmark sign of uterine infection. This finding, in conjunction with uterine tenderness and systemic symptoms, indicates likely endometritis.
  • Client reports feeling unwell: A nonspecific but important early sign of infection or systemic compromise. This symptom, when paired with objective findings, warrants prompt clinical attention.
  • Fundus boggy but firmed with massage, uterus tender to palpation: A boggy uterus suggests uterine atony, which increases hemorrhage risk. Although it responds to massage, it reflects poor uterine tone and requires monitoring. Tenderness supports the likelihood of endometritis,
  • Temperature 38.2° C (100.8° F): A postpartum temperature above 38° C, particularly after 24 hours, is considered abnormal and may indicate infection, especially when supported by other abnormal findings.

Rationale for Incorrect Findings:

  • Respiratory rate 18/min is within acceptable limits and do not indicate an immediate respiratory or circulatory emergency.
  • Surgical incision well approximated with slight edema; no redness or drainage: Minor swelling without other signs of infection (e.g., erythema, warmth, discharge) is expected and does not require urgent intervention.
  • No bowel movement since birth, hypoactive bowel sounds: Bowel inactivity is common postpartum, especially after cesarean and general anesthesia. While this warrants monitoring, it is not a priority unless symptoms worsen.
  • Lung sounds clear but diminished in the bases. This is commonly observed postpartum, especially following cesarean delivery under general anesthesia. It may be due to decreased mobility, shallow breathing, or atelectasis. While it is a point to monitor it is not urgent

Correct Answer is B

Explanation

A. 2+ deep-tendon reflexes: This is a normal reflex response and indicates that magnesium levels are not excessively high. Diminished or absent reflexes would be a more concerning sign of toxicity.
B. Respiratory rate 10/min: A respiratory rate below 12/min suggests respiratory depression, which is a serious adverse effect of magnesium sulfate toxicity. This is the priority finding requiring immediate intervention.
C. Urinary output 35 mL/hr: This is slightly above the minimum expected output of 30 mL/hr. While renal function must be monitored to prevent magnesium accumulation, this rate is adequate for now.
D. Pedal edema: Edema is common in preeclampsia and is not an urgent concern compared to signs of magnesium toxicity such as respiratory depression.

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