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.

Pressured speech

Disorganized thought process

Excessive spending habits

Hallucinations

Lack of sleep

Answer and Explanation

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

Pressured speech is a hallmark of mania, reflecting heightened psychomotor activity and accelerated thought processes. It often overwhelms conversation partners and makes logical communication difficult. This symptom reflects the individual’s racing mind and inability to filter or regulate their verbal output, often seen in manic episodes.
Disorganized thought process is seen in both psychosis and mania, but manifests differently in each. In psychosis, it is often due to a breakdown in logical thinking or connection to reality. In mania, it reflects flight of ideas, rapid topic shifting, and distractibility. The presence of both symptoms indicates overlapping features.
Excessive spending habits are consistent with manic behavior, often driven by grandiosity and poor judgment. Clients in a manic state may feel invincible or overly generous, leading them to make irrational financial decisions. These behaviors can result in significant personal or financial consequences, including debt or loss of savings.
Hallucinations are perceptual disturbances where individuals see, hear, or feel things that are not present, primarily associated with psychosis. Auditory hallucinations, like hearing voices or unseen persons, are especially common. This indicates a loss of reality testing, which is central to diagnosing psychotic disorders.
Lack of sleep without fatigue or distress is a key feature of mania, often preceding or accompanying a manic episode. Unlike insomnia in depression or anxiety, clients with mania may report feeling energetic and productive. The sleep deficit contributes to cognitive and emotional instability seen in manic phases.

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Correct Answer is A

Explanation

A. Muscle weakness: Hyperkalemia disrupts normal muscle cell function by affecting membrane excitability, leading to symptoms like muscle weakness or even paralysis in severe cases. It is one of the hallmark signs of elevated potassium levels.
B. Oliguria: While hyperkalemia may be associated with renal impairment, oliguria is not a direct manifestation of high potassium but rather a possible contributing factor. It is not specific to hyperkalemia itself.
C. Hypoactive bowel sounds: Increased potassium levels typically cause hyperactivity of the gastrointestinal tract, leading to hyperactive bowel sounds and cramping, not reduced or hypoactive activity.
D. Hypertension: Hyperkalemia more commonly results in hypotension due to its effects on cardiac conduction and vasculature. Hypertension is not a typical manifestation of elevated serum potassium.

A. Methylergonovine B. Carboprost C. Nifedipine D. Oxytocin

Correct Answer is D

Explanation

A. Methylergonovine: While effective for postpartum hemorrhage, it causes vasoconstriction and can raise blood pressure significantly. It is contraindicated in clients with preeclampsia or hypertension due to the risk of stroke or hypertensive crisis.
B. Carboprost: Carboprost is used to treat postpartum hemorrhage, but it may increase blood pressure and is used cautiously in clients with preeclampsia. It is not typically the first-line treatment in hypertensive patients.
C. Nifedipine: Nifedipine is a calcium channel blocker used for managing hypertension and preterm labor, not for controlling postpartum bleeding. It does not cause uterine contraction and is not effective for hemorrhage.
D. Oxytocin: Oxytocin stimulates uterine contractions and is the first-line medication for managing postpartum hemorrhage. It does not raise blood pressure, making it safe and effective for clients with preeclampsia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications?

Correct Answer is D

Explanation

A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the parent?

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

A nurse is caring for a client who is obese. The client is crying and states. "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the State health department?

A nurse is monitoring a client who is 36 hr postoperative following gastric banding. Which of the following findings should the nurse expect?

A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system in his home. Which of the following actions should the nurse take?

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

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.