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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.

Lack of sleep

B.

Pressured speech

C.

Disorganized thought process

D.

Excessive spending habits

E.

Hallucinations

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

  • Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
  • Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
  • Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
  • Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
  • Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.


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Related Questions

Correct Answer is B

Explanation

A. Place a small, folded blanket behind the baby's neck to provide support while in the car seat. Adding extra padding behind the infant’s neck is not recommended, as it can alter the positioning and compromise the safety design of the car seat. Only manufacturer-approved inserts should be used.
B. Anchor the car seat in a rear-facing position in the back seat of the vehicle. Infants under the age of 2 should always be placed in a rear-facing car seat in the back seat. This position offers the best protection for the infant’s head, neck, and spine in the event of a crash.
C. Ensure the water heater temperature is set to no more than 54° C (129.2° F). This temperature is too high and increases the risk of scalding. The recommended maximum temperature for a household water heater is 49° C (120° F) to ensure infant safety.
D. Cover the baby with a cotton blanket when they are asleep. Using loose bedding, including blankets, increases the risk of sudden infant death syndrome (SIDS). Instead, the infant should sleep in a wearable blanket or sleep sack on a firm mattress without soft items.

Correct Answer is C

Explanation

A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.

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