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 C
Explanation
A. “Use an indoor tanning bed instead of outside.”: Indoor tanning exposes the skin to concentrated ultraviolet radiation, which significantly increases the risk of developing skin cancer, including melanoma. It is not a safe alternative to outdoor sun exposure.
B. “Plan to spend time tanning between 10 am and 2 pm.”: This time frame represents peak UV radiation hours, and sun exposure should be minimized during this period to reduce the risk of skin damage and cancer.
C. “Apply sunscreen before and after swimming.”: Sunscreen should be applied 15–30 minutes before sun exposure and reapplied after swimming or sweating. Water can wash off sunblock, so reapplication helps maintain effective protection against UV rays.
D. “Use sunblock with an SPF of 10 when I am outdoors.”: An SPF of 10 provides minimal protection and is inadequate for preventing skin damage. A minimum SPF of 30 is recommended for effective protection against both UVA and UVB radiation.
Correct Answer is D
Explanation
A. Place the client in a side-lying position for the procedure: Paracentesis is typically performed with the client in an upright or high-Fowler’s position to allow fluid to pool in the lower abdomen for easier access and drainage.
B. Administer a low-volume hypertonic enema the night before the procedure: Enemas are not routinely indicated for paracentesis since the bowel does not obstruct access to ascitic fluid, making this an unnecessary step.
C. Ensure the client has a full bladder just prior to the procedure: A full bladder increases the risk of accidental puncture during needle insertion. The bladder should be emptied to reduce this risk.
D. Weigh the client before and after the procedure: Weighing the client allows the healthcare team to estimate the volume of ascitic fluid removed and assess fluid balance, making this a key nursing responsibility.
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