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

Explanation

The client presents with symptoms suggestive of severe preeclampsia, including headache, nausea, right upper quadrant pain, facial and dependent edema, rapid weight gain, and 3+ deep tendon reflexes (hyperreflexia). Hyperreflexia is a sign of central nervous system irritability, which can precede seizures (eclampsia) and increase the risk for placental abruption—a premature separation of the placenta from the uterine wall. This is a medical emergency that can result in fetal and maternal complications.

Correct Answer is A

Explanation

A. Respiratory rate 10/min. This is the priority finding because it suggests respiratory depression, a serious side effect of magnesium sulfate therapy. Magnesium acts as a CNS depressant, and a respiratory rate below 12/min is a potential sign of magnesium toxicity, which can lead to respiratory arrest if not promptly addressed.
B. 2+ deep-tendon reflexes. This indicates normal neuromuscular function and is actually a reassuring finding in a client receiving magnesium sulfate. Reflexes are typically monitored to detect early signs of toxicity, and a 2+ rating means the dose is likely therapeutic.
C. 3+ pedal edema. While significant, pedal edema is a common feature of preeclampsia and not directly related to magnesium sulfate toxicity. It should be monitored but does not require immediate action compared to respiratory compromise.
D. Urinary output 35 mL/hr. This is slightly above the minimum acceptable output of 30 mL/hr, indicating the kidneys are excreting adequately. While magnesium is excreted renally and output must be monitored, this value does not indicate an acute risk.

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