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

Hallucinations

Lack of sleep

Pressured speech

Excessive spending habits

Disorganized thought process

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Rationale:

Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","E","G"]

Explanation

Rationale for correct choices:

Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

A. "Refrain from doing any exercises until your symptoms show improvement." B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear." C. "Use your short-acting beta agonist inhaler before exercising." D. "It is safe to exercise if your peak flow meter measures in the red zone."

Correct Answer is C

Explanation

Rationale:

A. "Refrain from doing any exercises until your symptoms show improvement.": Completely avoiding exercise is not necessary for most people with asthma and can negatively impact cardiovascular health. The goal is to control symptoms so that safe activity is possible.

B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear.": Long-acting beta agonists are used for maintenance therapy, not for quick relief. They are not appropriate for immediate symptom control before or after exercise.

C. "Use your short-acting beta agonist inhaler before exercising.": Short-acting beta agonists, such as albuterol, can be taken 5–20 minutes before exercise to prevent exercise-induced bronchospasm. This is the recommended approach for clients with exercise-triggered asthma.

D. "It is safe to exercise if your peak flow meter measures in the red zone.": The red zone indicates severe airway narrowing and poor asthma control, requiring immediate medical attention. Exercise in this state could worsen symptoms and lead to respiratory distress.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

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

Correct Answer is ["A","B","D","E","G"]

Explanation

A nurse in a provider's office is caring for a client who has asthma and reports that the manifestations get worse while exercising. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?

A nurse in a provider's office is caring for a client. Exhibits The nurse is performing a fall risk assessment for the client. Select the 3 findings that place the client at risk for a fall.

A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?

A nurse is planning care for a client during Ramadan who is a devout Muslim. Which of the following actions should the nurse include regarding the client's diet?

A nurse and a newly licensed nurse are discussing effective communication techniques for a client who has expressive aphasia. Which of the following statements by the newly licensed nurse indicate understanding of the teaching?

A nurse is reviewing the medical history of a client who asks about the use of conjugated estrogen. The nurse should identify which of the following findings as a contraindication for the administration of this medication?

A nurse in the emergency department is caring for a client who has major burns. Which of the following actions should the nurse take?

A nurse is reviewing the facility's safety protocols concerning newborn abduction with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching?

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