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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 A

Explanation

A. Tell the client, "You seem to be very upset.": Using verbal de-escalation and acknowledging the client’s emotions can help reduce agitation. This approach demonstrates empathy, promotes communication, and can prevent escalation.

B. Use a face shield with a mask when providing care to the client: Personal protective equipment is important for infection control, but it does not address the behavioral escalation or help calm an agitated client.

C. Initiate seclusion protocol: Seclusion is a restrictive intervention used only if the client poses an imminent risk of harm. It is not the first step in managing agitation and should follow attempts at de-escalation.

D. Engage the panic alarm: Activating the panic alarm is appropriate in situations of immediate danger, but for verbal agitation and pacing without aggression, de-escalation is the first intervention.

Correct Answer is C

Explanation

Rationale:

A. Generativity vs self-absorption: This stage occurs in middle adulthood, typically between ages 40 and 65, when individuals focus on contributing to society, guiding the next generation, and creating a lasting legacy.

B. Trust vs mistrust: This is the first stage of Erikson’s theory, occurring in infancy (birth to 1 year). It centers on developing a sense of trust when basic needs are met consistently by caregivers.

C. Identity vs role confusion: This stage occurs during adolescence (approximately ages 12 to 18) and involves exploring personal values, beliefs, and goals to develop a stable sense of self. Success leads to identity formation, while failure results in role confusion.

D. Intimacy vs isolation: This stage takes place in young adulthood (approximately ages 20 to 40) and focuses on forming deep, committed relationships while balancing independence and emotional closeness.

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