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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":"C","dropdown-group-2":"D"}

  • Panic disorder: Typically presents with intense fear, chest pain, shortness of breath, dizziness, and a sense of doom. It is episodic, not sustained like mania, and does not include symptoms like euphoria, grandiosity, or hallucinations.
  • Catatonia: Involves motor immobility, stupor, rigidity, or excessive purposeless movement. While this client is very active, their activity is goal-directed but disorganized, consistent with mania, not catatonia.
  • Mania: Characterized by euphoric or irritable mood, increased energy, racing thoughts, pressured speech, poor judgment, impulsivity, and decreased need for sleep. The client displays grandiosity, impulsive spending, hyperactivity, pressured speech, insomnia, and hallucinations, all pointing to mania.
  • Major depressive disorder: Involves symptoms like anhedonia, depressed mood, fatigue, and decreased energy. This is inconsistent with the client's overactivity and euphoric behavior.
  • Delirium: Usually presents with acute confusion, fluctuating consciousness, and disorientation, often due to a medical condition or substance use. This client is consistently manic and does not show signs of fluctuating alertness or disorientation to time and person.
  • Anhedonia: Inability to feel pleasure, commonly seen in depression, not in mania.
  • Alogia: Poverty of speech or reduced speech output, often associated with schizophrenia, not consistent with this client’s pressured and loud speech.
  • Magical thinking: Believing that one's thoughts can influence reality, often seen in schizotypal personality disorder, not prominent here.
  • Euphoric mood: A classic symptom of mania, where the individual may feel overly joyful, energetic, and invincible, as reflected in the client's excessive confidence, impulsivity, and erratic behavior.
  • Hypervigilance: Commonly linked with anxiety disorders or PTSD, and not the most fitting descriptor for this client’s presentation.


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Related Questions

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

  • Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
  • Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
  • Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
  • Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
  • Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.

Correct Answer is D

Explanation

A. Discuss the client's preferences for determining a repositioning schedule. While it's important to consider the client's comfort, repositioning must follow clinical guidelines (typically every 2 hours) to prevent pressure injuries, especially in clients with limited mobility post-stroke.
B. Raise the side rails on both sides of the client's bed during repositioning. Raising both side rails can be considered a form of restraint if not medically justified. Only one rail should be raised for safety and support unless otherwise indicated by facility policy.
C. Reposition the client without the use of assistive devices. Repositioning a client post-stroke without proper equipment increases the risk of injury to both the client and the nurse. Assistive devices promote safety and proper body mechanics.
D. Evaluate the client's ability to help with repositioning. This is the first and most important step. Assessing the client’s physical capability and level of consciousness ensures that the nurse uses the appropriate technique and equipment for safe repositioning.

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