The nurse continues to care for the client.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
Excessive spending habits
Hallucinations
Pressured speech
Lack of sleep
Disorganized thought process
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}
Rationale:
- Excessive spending habits: This behavior is hallmark for mania, where impaired judgment, impulsivity, and inflated self-esteem lead to reckless financial decisions.
- Hallucinations: Hallucinations, especially visual or auditory ones, are classic signs of psychosis. They indicate a break from reality and are not a diagnostic feature of mania alone unless psychotic features are present.
- Pressured speech: Pressured, rapid, and loud speech is a diagnostic feature of mania, reflecting heightened psychomotor activity and racing thoughts.
- Lack of sleep: Insomnia without fatigue is typical in mania. Clients may stay awake for days with increased energy levels and no perceived need for rest.
- Disorganized thought process: This can appear in both mania and psychosis. In mania, it stems from flight of ideas and distractibility. In psychosis, it results from impaired reality testing and cognitive disintegration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. First-degree atrioventricular block: A first-degree AV block is characterized by a prolonged but consistent P-R interval greater than 0.20 seconds. A P-R interval of 0.35 seconds with no dropped beats is a classic sign of this dysrhythmia.
B. Atrial fibrillation: Atrial fibrillation presents with an irregularly irregular rhythm and absent distinct P waves. The presence of a consistent P-R interval rules out atrial fibrillation.
C. Premature atrial complexes: PACs are identified by early P waves that may look different from sinus P waves, often followed by a normal QRS complex. They do not cause consistently prolonged P-R intervals.
D. Complete heart block: Complete (third-degree) heart block involves no association between P waves and QRS complexes. The atria and ventricles beat independently, which contradicts the presence of a consistent P-R interval.
Correct Answer is A
Explanation
Rationale:
A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.
B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.
C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.
D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.
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