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 a low-protein diet for the child: A low-protein diet is not indicated for neutropenia and may impair healing and immune function. Adequate nutrition, including sufficient protein, supports recovery and immune response.
B. Screen the child's visitors for active infections: Neutropenia significantly increases the risk of infection due to low white blood cell counts, so screening visitors for active infections helps reduce the chance of exposing the child to infectious agents.
C. Monitor the child for indications of active bleeding: While bleeding risk is important in leukemia, neutropenia specifically refers to decreased neutrophils affecting infection risk rather than platelets, so bleeding monitoring is important but not the primary focus here.
D. Prepare the child for a platelet transfusion: Platelet transfusions are used to address thrombocytopenia, not neutropenia. Transfusions may be needed in leukemia but are not directly related to neutropenia care.
Correct Answer is C
Explanation
A. Metabolic acidosis: Small bowel obstructions are more commonly associated with metabolic alkalosis due to loss of gastric contents from vomiting. Acidosis is less typical in the early stages of obstruction.
B. Hyperactive bowel sounds: In nonmechanical (paralytic ileus) obstruction, bowel sounds are usually absent or hypoactive, not hyperactive, due to lack of peristalsis. Hyperactive sounds are more typical in early mechanical obstruction.
C. Distended abdomen: Abdominal distention is a classic sign of bowel obstruction, resulting from gas and fluid accumulation above the site of obstruction. It is expected in both mechanical and nonmechanical types.
D. Passing flatus: The absence of flatus is common in bowel obstruction, as bowel movement is halted. Continued passage of flatus would suggest partial or resolving obstruction, not a typical finding in active nonmechanical obstruction.
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