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.
Pressured speech
Disorganized thought process
Excessive spending habits
Hallucinations
Lack of sleep
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Initiate fundal massage: Fundal massage is typically used postpartum to stimulate uterine contraction and prevent hemorrhage, not during active labor, so this is not appropriate at this stage.
B. Apply a fetal heart rate monitor: Monitoring the fetal heart rate is essential after membrane rupture to assess fetal well-being and detect signs of distress during labor, making this the priority action.
C. Insert an indwelling urinary catheter: While sometimes necessary during labor if the client cannot void, catheter insertion is not a routine first action and depends on the client’s condition and labor progress.
D. Initiate an oxytocin IV infusion: Oxytocin is used to induce or augment labor but should only be started based on the healthcare provider’s order and assessment of labor progression, not immediately after membrane rupture.
Correct Answer is C
Explanation
A. Remove the peripheral IV site: The IV site should be maintained with normal saline to keep access open for potential emergency medications or further treatment. Removing it too early may hinder urgent intervention.
B. Infuse 0.9% sodium chloride through the infusion set tubing: Normal saline should be infused after stopping the transfusion, but it must be done through new tubing to avoid continued exposure to the blood product.
C. Stop the transfusion of the blood: Itching and flushing are signs of a mild allergic transfusion reaction. The immediate priority is to stop the transfusion to prevent the reaction from progressing. This action helps prevent further antigen exposure.
D. Monitor the client's vital signs every 30 min: While vital sign monitoring is important, it is not the first or most urgent action. The priority is to stop the transfusion and address the reaction promptly.
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