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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

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.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. "I will hang a pastel-colored mobile 24 inches above my baby's crib.": Newborns can only see objects clearly 8–12 inches away and are more attracted to bold patterns and contrasting colors. A mobile 24 inches away would be too far for visual stimulation.

B. "I will place a ticking clock nearby to soothe my baby throughout the day.": Rhythmic sounds, such as a ticking clock, can mimic the intrauterine environment and help calm newborns. This is an appropriate soothing technique for a 1-week-old.

C. "I will avoid picking up my baby too often to keep from spoiling him.": Holding and responding promptly to a newborn’s needs promotes bonding, emotional security, and healthy development. At this age, infants cannot be spoiled.

D. "I can use a firm pillow to prop up the bottle when feeding my baby.": Propping bottles increases the risk of choking, aspiration, and otitis media. Infants should always be held during feedings for safety and bonding.

Correct Answer is C

Explanation

Rationale:

A. Check the compatibility of cefazolin with the client's existing IV fluids: Compatibility is important to prevent precipitation or inactivation of the drug, but it should be done only after confirming the medication is safe for the client to receive.

B. Assess the IV for patency: Ensuring the IV line is patent is necessary before administration to avoid infiltration or extravasation, but it is not the first priority when preparing a first-time antibiotic dose.

C. Review the client's allergy history: Reviewing allergies is the first and most critical step, as cefazolin is a cephalosporin that can cause severe allergic reactions, particularly in clients with a history of beta-lactam (e.g., penicillin) allergy. Administering the drug without this check could cause life-threatening anaphylaxis.

D. Obtain the reconstituted antibiotic from the pharmacy: Securing the medication from the pharmacy is part of preparation, but this should only occur after confirming it is safe for the client to receive based on allergy status.

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