Try Naxlex NCLEX-RN (Free-Trial)

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

A.

Hallucinations

B.

Lack of sleep

C.

Pressured speech

D.

Excessive spending habits

E.

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

Rationale for correct choices:

• Reye’s syndrome is a rare but serious condition that can develop after a viral illness when aspirin is given to children. The toddler’s symptoms—lethargy, persistent vomiting, and difficulty rousing—align with signs of increased intracranial pressure associated with Reye’s syndrome.

• Aspirin administration during a recent influenza A infection is a known trigger for Reye’s syndrome, as it can cause acute encephalopathy and liver dysfunction in pediatric patients.

Rationale for incorrect choices:

• Bronchitis would present with prominent lower respiratory symptoms such as productive cough, wheezing, and abnormal lung sounds, which are not noted here.

• Gastroenteritis is characterized by vomiting and diarrhea with signs of dehydration; this child has no diarrhea, and the neurological decline suggests CNS involvement rather than a purely GI process.

• Acetaminophen administration is not linked to Reye’s syndrome; toxicity causes liver injury but does not present with acute encephalopathy following viral illness in the same way.

• Cough finding is unrelated to the primary cause of the neurological changes and persistent vomiting; the cough has been present but is not the trigger for the current complication.

Correct Answer is D

Explanation

A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.

B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.

C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.

D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register