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
Hallucinations
Disorganized thought process
Lack of sleep
Excessive spending habits
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Rationale:
• Pressured speech: The client demonstrates rapid, loud, and nonstop speech, characteristic of mania. Pressured speech reflects heightened energy, distractibility, and decreased need for rest, all typical of a manic episode. It is not a primary symptom of psychosis, although severe psychotic agitation can sometimes alter speech.
• Hallucinations: The client reports seeing a person who is not present and interacting with them, which is a hallmark of psychosis. These perceptual disturbances indicate impaired reality testing. Hallucinations are less common in purely manic states unless mania is accompanied by psychotic features. Here, the client’s persistent visual hallucinations support a diagnosis of psychosis.
• Disorganized thought process: The client exhibits disorganized and tangential speech, reflecting difficulty organizing thoughts. Disorganization is characteristic of psychotic disorders due to impaired reality testing and cognitive processing. It can also appear in mania, particularly when the client exhibits distractibility, racing thoughts, and pressured speech.
• Lack of sleep: The client has gone at least 2 days without sleeping, a classic sign of mania. Decreased need for sleep with preserved energy is typical in manic episodes. Sleep deprivation alone does not indicate psychosis unless accompanied by hallucinations or delusions.
• Excessive spending habits: The client exhibits impulsive financial behavior, giving away large sums of money and overspending. This risk-taking and poor judgment are hallmark features of mania. Such behaviors are less commonly associated with psychosis unless delusions drive them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Encourage the client to participate in a diabetes mellitus support group: While support groups are beneficial for emotional support and ongoing education, this intervention is not the priority during the initial home visit. It is more appropriate once the client’s knowledge and self-care skills have been assessed.
B. Determine the client's level of health literacy: Assessing health literacy is the first priority because it guides the nurse in tailoring education and interventions. Understanding the client’s ability to comprehend and apply health information ensures that teaching about diabetes management, such as glucose monitoring and medication administration, is effective and safe.
C. Verify the client's comfort level regarding how to use a glucometer: Ensuring the client can correctly use a glucometer is important, but this step should follow the assessment of health literacy. Tailoring instruction to the client’s literacy level improves comprehension and accuracy in self-monitoring.
D. Provide low-carbohydrate recipes for the client: Providing dietary resources supports diabetes management but is secondary to assessing the client’s understanding and ability to implement self-care. Without first evaluating literacy and comprehension, these resources may not be effectively utilized.
Correct Answer is A
Explanation
A. The client started working in a parking garage 3 months ago: Working in a parking garage can increase exposure to carbon monoxide and other exhaust fumes, which can be harmful to both the pregnant client and the fetus. Prolonged inhalation of these toxins may reduce oxygen delivery and contribute to complications, making this finding a priority for further evaluation.
B. The client is doing 30 min of moderate exercise daily: Moderate exercise is recommended during pregnancy as it improves circulation, reduces stress, and supports healthy weight gain. This behavior is considered safe and beneficial unless otherwise contraindicated by the provider.
C. The client is drinking 2.5 L of water per day: Adequate hydration is essential during pregnancy to support amniotic fluid levels, circulation, and kidney function. A daily intake of 2.5 liters is appropriate and aligns with recommended guidelines for pregnant clients.
D. The client last visited the dentist 4 months ago: Routine dental care is important during pregnancy due to increased risk of gingivitis, but a dental visit 4 months ago does not indicate an unsafe behavior. Continuing regular appointments every 6 months is generally sufficient unless specific concerns arise.
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