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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 B

Explanation

A. "A cesarean birth is the only way to prevent transmission." Cesarean delivery is considered if active lesions or prodromal symptoms are present at the time of labor. However, it is not automatically required for all clients with a history of herpes.
B. "If you notice genital tingling be sure to notify your provider." Genital tingling or burning can be a prodromal sign of an impending herpes outbreak. Early reporting allows for appropriate evaluation and potential antiviral treatment to reduce the risk of transmission to the newborn.
C. "Hydrotherapy during labor can help reduce transmission." Hydrotherapy has no effect on herpes virus transmission and is not used for this purpose. Preventing neonatal herpes depends on careful monitoring and antiviral management.
D. "The provider will perform weekly visual inspections for lesions." Routine weekly inspections are not standard unless symptoms suggest an outbreak. Clients are generally monitored and evaluated for lesions closer to labor or if symptoms arise.

Correct Answer is B

Explanation

A. Irrigate the wound using a 10-mL syringe. A 10-mL syringe does not provide adequate pressure for effective irrigation. Typically, a 30- to 60-mL syringe with an 18-gauge catheter is used to deliver appropriate pressure (between 4–15 psi) to clean wounds effectively.
B. Irrigate the wound with a low-pressure flow of solution. This is correct. A low-pressure irrigation system helps gently remove debris and bacteria without damaging healthy tissue. It also minimizes the risk of forcing contaminants deeper into the wound bed.
C. Cleanse the insertion site of the drain using a circular motion toward the center. The site should be cleansed from the center outward, not toward the center, to prevent dragging contaminants into the insertion site and reduce infection risk.
D. Cleanse the wound starting at the bottom and moving upward. Wound cleaning should occur from the least contaminated (top) to the most contaminated (bottom) area to avoid transferring microorganisms from dirtier areas to cleaner areas, thereby minimizing the risk of infection.

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