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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["140"]
Explanation
Calculation:
- Convert the client's current weight from kilograms (kg) to pounds (lbs).
Current weight (lbs) = Patient weight (kg) x Conversion factor (lbs/kg)
= 75 kg x 2.2 lbs/kg
= 165 lbs.
- Calculate the total weight loss over 25 weeks.
Total weight loss (lbs) = Weight loss per week (lbs) x Number of weeks
= 1 lb/week x 25 weeks
= 25 lbs.
- Calculate the expected goal weight in pounds (lbs).
Goal weight (lbs) = Current weight (lbs) - Total weight loss (lbs)
= 165 lbs - 25 lbs
= 140 lbs.
Correct Answer is B
Explanation
Rationale:
A. "I will use an interpreter when providing client teaching.": An interpreter is useful for clients with language barriers. Expressive aphasia affects speech production, not comprehension, so an interpreter would not address the main communication challenge.
B. "I will use a communication board to assess the client's needs.": A communication board allows the client to point to words, pictures, or symbols to express thoughts and needs without relying on verbal speech. This is an effective method for facilitating communication with expressive aphasia.
C. "I will provide written instructions for the client in 8-point font.": Written instructions can help if reading skills are intact, but 8-point font is too small for easy readability, especially for clients who may also have vision changes. Larger, clear print is recommended.
D. "I will use indirect lighting in the client's room.": Lighting preferences may improve comfort, but they do not address the core communication difficulty caused by expressive aphasia. This intervention is unrelated to improving the client-nurse communication.
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