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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Client reports popping sensation at the wound: A popping or tearing sensation at the surgical site can indicate wound dehiscence or evisceration, which is a surgical emergency. Immediate reporting to the provider is essential for prompt intervention to prevent further complications.

B. Client is tender to touch at the surgical site: Mild tenderness is expected 24 hours postoperatively due to inflammation and tissue trauma. While it should be monitored, it is not an urgent finding requiring immediate provider notification.

C. Crusting on the client's incision line: Light crusting is a normal part of the healing process and does not typically indicate a complication. Routine wound care and monitoring are sufficient.

D. Serosanguineous drainage on the client's dressing: Serosanguineous drainage is expected within the first 24–48 hours after surgery. It is a normal finding and usually does not require urgent reporting unless it increases significantly or changes character.

A. Withdraw dose of regular insulin. B. Inject air into the vial of regular insulin. C. Inject air into the vial of NPH insulin. D. Withdraw dose of NPH insulin.

Correct Answer is C

Explanation

A. Withdraw dose of regular insulin: Withdrawing the regular insulin dose is performed after the air has been injected into both vials and the NPH insulin has been drawn up if using the “clear before cloudy” technique. Doing this first would risk disrupting the proper sequence and potentially contaminating the insulin.

B. Inject air into the vial of regular insulin: Air must be injected into the regular insulin vial before withdrawing the medication, but this step is performed after first injecting air into the NPH vial according to the standard procedure for mixing insulins. Starting with the regular insulin vial would not follow the recommended order.

C. Inject air into the vial of NPH insulin: Injecting air into the NPH insulin vial first is the initial step when preparing a mixed insulin dose. This step equalizes pressure inside the vial, allowing for easier withdrawal later, and follows the correct sequence of “air into cloudy first, then clear,” which prevents contamination of the regular insulin.

D. Withdraw dose of NPH insulin: Withdrawing NPH insulin is done after the regular insulin has been drawn into the syringe to maintain the correct “clear before cloudy” technique. Doing this first could result in accidental mixing or contamination of the regular insulin.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 24 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is preparing to mix a dose of NPH insulin and regular insulin into a single syringe. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse manager is teaching a group of nurses about bacterial meningitis. Which of the following information should the nurse include in the teaching?

The nurse is continuing to care for the client. The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.

A mental health nurse is caring for a client who recently attempted to self-harm. The client states, "I wish I were dead." Which of the following responses should the nurse make?

A nurse is performing a gait assessment on a client to evaluate the client's ability to perform ADLs. Which of the following findings indicates a standard gait?

A nurse is providing teaching to a client who is formula feeding their newborn. Which of the following information should the nurse include in the teaching to minimize their newborn's spit-up?

The nurse is continuing to care for the client. The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

A nurse manager suspects a health care worker is experiencing chemical impairment. Which of the following actions should the nurse manager take first?

A nurse is planning care for a client who is to begin receiving hospice care. Which of the following interventions should the nurse include in the plan?

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.