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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Irrigate the wound with a low-pressure flow of solution: Low-pressure irrigation (typically using a 30–60 mL syringe with an 18-gauge catheter) effectively removes debris and reduces tissue trauma, promoting wound healing while preventing the spread of bacteria deeper into the tissue.
B. Cleanse the insertion site of the drain using a circular motion toward the center: Wound cleansing should proceed from the center outward, not toward the center, to avoid introducing contaminants into the wound or insertion site.
C. Cleanse the wound starting at the bottom and moving upward: Wound cleansing should always be done from the cleanest to dirtiest area starting at the top (incision site) and moving downward, not the reverse, to prevent contamination.
D. Irrigate the wound using a 10 mL syringe: A 10 mL syringe does not generate sufficient volume or pressure for effective wound irrigation. Larger syringes (30–60 mL) are preferred to provide adequate flow for proper cleansing.

A. Insert the oral thermometer in front of the infant's tongue. B. Place the tip of the thermometer under the center of the infant's axilla. C. Pull the pinna of the infant's ear forward before inserting the probe. D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.

Correct Answer is B

Explanation

A. Insert the oral thermometer in front of the infant's tongue: Oral temperature is not recommended for infants due to the risk of injury and difficulty keeping the thermometer in place.
B. Place the tip of the thermometer under the center of the infant's axilla: The axillary route is safe and appropriate for infants. Ensuring the tip is in full contact with the skin in the center of the axilla ensures a more accurate reading.
C. Pull the pinna of the infant's ear forward before inserting the probe: For infants under 3 years, the pinna should be pulled down and back to straighten the ear canal, not forward.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is excessive for an infant; rectal insertion should be only about 1.3 to 2.5 cm (0.5 to 1 in) to avoid rectal trauma.

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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 performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

Correct Answer is A

Explanation

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a newborn who is receiving phototherapy treatment. Which of the following actions should the nurse take?

A nurse is caring for a client who is postoperative following total hip arthroplasty. Which of the following actions should the nurse take to prevent dislocation of the prosthesis?

A nurse is providing a change-of shift report about a client who is 36 hr postoperative to another nurse. Which of the following information should the nurse include in the report?

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

A nurse is caring for a client who has just started having a seizure. Which of the following interventions should the nurse implement?

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

A nurse on a medical-surgical unit is planning care for assigned clients. Which of the following actions should the nurse plan to take to demonstrate effective time management?

A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

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.