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The nurse continues to care for the client.

Exhibits

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":"C"}

Rationale for correct choices:

  • Mania: The client exhibits classic signs of mania, including decreased need for sleep, excessive energy, impulsive spending, grandiosity, pressured and disorganized speech, and poor self-care. These behaviors reflect a manic episode, often seen in bipolar disorder, which requires careful monitoring and intervention.
  • Euphoric mood: The client demonstrates an abnormally elevated and joyous mood, along with inflated self-confidence and excessive sociability. This euphoric mood is a hallmark feature of mania and differentiates it from other psychiatric conditions such as depression or delirium.

Rationale for incorrect choices:

  • Major depressive disorder: This disorder presents with persistent low mood, anhedonia, and decreased energy. The client displays the opposite symptoms, including hyperactivity, elevated mood, and impulsivity, making depression an unlikely diagnosis.
  • Delirium: Delirium is characterized by an acute change in attention, confusion, and disorientation, often fluctuating throughout the day. While the client is disoriented to place, the presence of sustained elevated mood and hyperactivity supports mania rather than delirium.
  • Panic disorder: Panic disorder involves sudden, intense episodes of fear with physical symptoms like palpitations, shortness of breath, and sweating. The client’s presentation is chronic and includes mood elevation and impulsive behaviors, which are inconsistent with panic disorder.
  • Catatonia: Catatonia involves motor immobility, mutism, or extreme negativism. The client is highly active, with constant movement and pressured speech, which is the opposite of catatonic presentation.
  • Anhedonia: Anhedonia refers to the inability to experience pleasure and is a symptom of depression. The client shows excessive pleasure-seeking behaviors, including socializing and impulsive spending, making anhedonia inconsistent with the current presentation.
  • Hypervigilance: Hypervigilance involves heightened alertness and exaggerated startle response, often seen in anxiety or PTSD. The client’s primary features are elevated mood and impulsive behavior rather than persistent vigilance.
  • Magical thinking: Magical thinking involves believing that one’s thoughts or actions can influence unrelated events. While the client reports hallucinations, there is no evidence of magical thinking as the hallucinations do not involve causative beliefs.
  • Alogia: Alogia is a reduction in speech output, typically seen in schizophrenia or severe depression. The client’s speech is pressured, loud, and disorganized, which is opposite to alogia.


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Related Questions

Correct Answer is D

Explanation

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.

Correct Answer is B

Explanation

A. Observe the client's range of movement: While monitoring physical status is important, mechanical restraints restrict movement, so assessing the client’s psychological triggers and safety is higher priority to prevent further aggression.

B. Identify stressors that caused the client's aggression: Understanding and addressing the factors that led to aggressive behavior is essential while the client is in restraints. This assessment helps in developing strategies to reduce agitation and prevent future episodes.

C. Hold a critical incident debriefing about the client: Debriefing is conducted after the event to support staff and evaluate interventions. It is not performed while the client is actively restrained.

D. Maintain sensory stimulation for the client: Providing excessive sensory stimulation during restraint can increase agitation and risk of injury. The focus should be on calming the client and ensuring safety rather than maintaining stimulation.

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