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

Explanation

Miosis : Pinpoint pupils are a hallmark of opioid overdose due to stimulation of the parasympathetic nervous system. This finding helps distinguish opioid toxicity from other types of substance use, which often cause pupil dilation instead.

Respiratory depression : Opioids depress the medullary respiratory centers in the brainstem, leading to slowed breathing. A respiratory rate of 10/min is significantly reduced and signals impaired ventilation, making it a critical diagnostic clue.

Opioid overdose: The clinical signs—needle marks, sedation, pinpoint pupils, bradypnea, and a positive response to naloxone—all strongly point to an opioid overdose. A similar prior episode adds to the likelihood of chronic opioid misuse.

Alcohol intoxication: While alcohol can depress the central nervous system, it does not typically cause miosis or respond to naloxone. Also, the pattern of rapid reversal with naloxone suggests opioid involvement rather than alcohol alone.

Benzodiazepine overdose: Though it shares features like sedation and respiratory depression with opioid overdose, benzodiazepine toxicity does not cause miosis, and naloxone has limited or no effectiveness as a reversal agent.

Cocaine intoxication : Typically causes stimulant effects including mydriasis (dilated pupils), increased heart rate, hypertension, and agitation. These are not consistent with the symptoms in this case, which reflect CNS depression.

Correct Answer is ["B","C","D"]

Explanation

A. "Blurred vision is an expected adverse effect of this medication." Blurred vision is not a common or expected adverse effect of lithium. If this occurs, it may indicate toxicity or another underlying issue and should be reported. It is not part of routine education for expected side effects.
B. "This medication can cause weight gain." This is true. Weight gain is a known long-term adverse effect of lithium therapy and should be discussed with the client and family as part of monitoring and lifestyle considerations during treatment.
C. "This medication can cause nausea and drowsiness." These are common initial side effects when starting lithium and usually subside over time. Clients should be aware of these effects so they can differentiate between expected reactions and signs of toxicity.
D. "It will take at least a week before this medication reaches a therapeutic level." Correct. Lithium takes 7–14 days to reach therapeutic plasma levels, so clients may not experience symptom relief immediately. During this period, supportive care and safety monitoring are essential.
E. "You will be placed on a low-sodium diet while taking this medication." This is incorrect. Lithium has a narrow therapeutic index, and sodium levels affect lithium levels. A low-sodium diet can increase the risk of lithium toxicity, so clients should maintain a consistent sodium intake, not reduce it.

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