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The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

A.

Excessive spending habits

B.

Hallucinations

C.

Pressured speech

D.

Lack of sleep

E.

Disorganized thought process

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Initiate fundal massage: Fundal massage is performed after delivery to prevent or manage uterine atony and postpartum hemorrhage. It is not appropriate during active labor, especially before the birth of the fetus.

B. Apply a fetal heart rate monitor: After rupture of membranes, there is an increased risk of umbilical cord prolapse or fetal distress. Continuous fetal monitoring is essential to assess fetal well-being and detect complications promptly.

C. Insert an indwelling urinary catheter: While catheterization may be done later, especially before epidural placement or cesarean delivery, it is not the most urgent action. It does not address immediate risks associated with ruptured membranes.

D. Initiate an oxytocin IV infusion: Oxytocin is used to augment or induce labor, but should not be started without first assessing fetal status. Fetal monitoring is necessary to establish a baseline before initiating uterotonic agents.

Correct Answer is A

Explanation

Rationale:

A. Rise slowly when getting out of bed: Furosemide can cause orthostatic hypotension due to fluid volume depletion. Instructing the client to rise slowly helps prevent dizziness, lightheadedness, and falls when changing positions.

B. Taking furosemide can cause your potassium levels to be high: Furosemide is a loop diuretic that promotes potassium loss through the urine. Hypokalemia is a common side effect, not hyperkalemia, and potassium levels should be monitored regularly.

C. Taking furosemide can cause you to be overhydrated: Furosemide works by removing excess fluid, which reduces the risk of fluid overload. However, overdiuresis can lead to dehydration, not overhydration, if fluid losses exceed intake.

D. Eat foods that are high in sodium: Clients with heart failure are typically advised to restrict sodium intake to prevent fluid retention and worsening of symptoms. High sodium intake can counteract the therapeutic effects of diuretics like furosemide.

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