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.

Rationale for Correct Choices:

• Mania is characterized by an abnormally elevated, expansive, or irritable mood accompanied by increased energy or activity. This client’s obsessive cleaning, excessive spending, sleeplessness, pressured speech, and overly joyous behavior strongly support a manic episode.
• Euphoric mood refers to an exaggerated feeling of well-being or elation not consistent with the client's circumstances. It often presents in mania alongside impulsivity and grandiosity, such as the client’s obsession with hosting parties and giving away money without regard for consequences.

Rationale for Incorrect Choices:

• Delirium: Typically presents with fluctuating consciousness, acute onset confusion, and disorganized thinking often due to a medical cause. The client is alert and oriented to person and time, which is inconsistent with the inattention and acute cognitive changes of delirium.
• Catatonia: Characterized by motor immobility, extreme negativism, mutism, or stupor. The client displays hyperactivity and pressured speech, which are the opposite of the psychomotor retardation seen in catatonia.
• Panic disorder: Involves sudden onset of intense fear with physical symptoms such as palpitations, chest pain, or shortness of breath. It lacks the prolonged mood elevation, impulsivity, and grandiosity observed in this case.
• Major depressive disorder: Presents with persistent sadness, fatigue, anhedonia, and social withdrawal. The client’s symptoms of increased activity, grandiosity, and reduced need for sleep do not align with depression.

• Alogia: Refers to poverty of speech or reduced speech output, often associated with schizophrenia or severe depression. This contrasts with the client’s pressured and excessive speech.
• Magical thinking: Involves believing one’s thoughts can influence the physical world, often seen in psychotic disorders or schizotypal personality disorder. The client describes hallucinations, but no evidence of magical thinking is present.
• Hypervigilance: Describes excessive alertness or scanning for threats, commonly associated with anxiety or PTSD. The client’s symptoms point to elevated mood and disinhibition, not heightened fear or threat perception.
• Anhedonia: A core symptom of depression, characterized by a loss of interest or pleasure in activities. The client’s increased goal-directed activity and enjoyment in planning events contradict this finding.

Rationale for Correct Choices:

• Antibiotic prescription: The client presents with signs of a postoperative wound infection: fever (38.8°C), increased WBC count (14,800/mm³), purulent drainage, and incisional swelling. These findings warrant prompt antibiotic therapy to prevent further complications.
• WBC count: The rise in WBC count from 8,000 to 14,800/mm³ over three days is a key indicator of an infectious process, particularly concerning postoperatively. It supports the need for antibiotics.
• Temperature: The client’s fever (38.8°C/101.8°F) is consistent with a systemic response to infection. In combination with the elevated WBC and wound findings, it confirms the need for antimicrobial treatment.

Rationale for Incorrect Choices:

• IV fluids: While fluids are essential postoperatively, the client shows no signs of hypovolemia or dehydration—mucous membranes are moist and blood pressure is stable. Fluids are not the priority.
• Laxative: Although the client hasn’t had a bowel movement, they are passing flatus and show some motility. The acute concern is infection, not constipation, making laxatives inappropriate as the primary intervention.
• Prescription for IV iron: The client has stable but low hemoglobin levels (around 10.3 g/dL), likely due to surgery. However, there’s no acute drop or symptomatic anemia requiring immediate IV iron over addressing infection.
• Hemoglobin: Although low, the hemoglobin level is stable and does not indicate an acute issue. It does not justify antibiotic use or serve as the primary clinical concern at this time.
• Bowel sounds: Hypoactive bowel sounds are common postoperatively and are not indicative of infection alone. They do not support the use of antibiotics directly.
• Blood pressure: The client’s blood pressure remains within normal limits postoperatively and does not show signs of septic or hypovolemic shock. It’s not relevant to initiating antibiotics.
• Transferrin level: Transferrin reflects protein status and iron transport; although low, it doesn’t indicate acute infection. It is unrelated to the decision to initiate antibiotics.
• Skin turgor: Normal skin turgor suggests adequate hydration. There’s no indication of dehydration or fluid imbalance requiring action.
• Bowel movements: Absence of bowel movement is common postoperatively and expected after colon surgery. While important to monitor for ileus, these are not the primary indicators for an antibiotic prescription.