The nurse continues to care for the client.
Fill in each blank in the following sentence.
The client is most likely experiencing <div id="dropdown-group-1">dropdown</div> as evidenced by the client's <div id="dropdown-group-2">dropdown</div>.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Explanation
- Lymphadenopathy: Generalized lymphadenopathy, or swelling of the lymph nodes, is a common symptom of measles and rubella, but not typically a defining feature of fifth disease.
- Koplik spots in the mouth: Pathognomonic for measles, appearing as tiny white lesions on the buccal mucosa before the rash. Their presence essentially confirms measles over other viral exanthems.
- Red rash on the face: Occurs in all three illnesses but with different patterns — measles starts at the hairline and spreads downward, rubella begins on the face and spreads quickly, and fifth disease presents with a “slapped cheek” appearance before spreading.
- Fever: Common to all three conditions but differs in severity — measles typically produces higher fevers, rubella causes mild fever, and fifth disease may have low-grade fever or none.
Correct Answer is C
Explanation
A. Explaining the steps for a 24-hr urine collection: Teaching and explaining procedures require nursing knowledge and judgment, which are outside the scope of practice for assistive personnel.
B. Interpreting blood glucose values: Interpretation of lab results requires clinical judgment and assessment skills, which must be performed by a licensed nurse.
C. Performing postmortem care: Postmortem care is a noninvasive task that focuses on preparing the body, maintaining dignity, and basic hygiene. This task is within the scope of practice for assistive personnel.
D. Assisting with low-carbohydrate diet selections: Assisting with dietary teaching or making food choices involves clinical guidance and education, which must be performed by a licensed nurse or dietitian rather than an assistive personnel.
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