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 C

Explanation

A. "Wear a pair of disposable briefs at bedtime.": Using briefs may provide protection against leakage but does not address the underlying bladder control issue. Bladder retraining focuses on strengthening muscles and establishing voiding schedules.

B. "Limit oral fluid intake to 1,000 milliliters per day.": Restricting fluids can lead to dehydration and urinary tract infections. Adequate hydration is important for bladder health, and fluid restriction is not a recommended strategy for retraining.

C. "Practice pelvic-floor exercises regularly.": Pelvic-floor (Kegel) exercises strengthen the muscles that support bladder control, improve continence, and are a key component of bladder retraining programs. Consistent practice enhances effectiveness over time.

D. "Drink 8 ounces of citrus juice per day.": Citrus juice is not necessary for bladder retraining and may irritate the bladder in some individuals. Dietary recommendations should focus on overall hydration and bladder-friendly fluids rather than specific juices.

A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter.

Correct Answer is D

Explanation

A. Request an interpreter of a different sex from the client: The interpreter’s sex should ideally match the client’s preference for comfort and privacy, but this is not the first action. The priority is understanding facility policy and proper use of interpreters.

B. Request a family member or friend to interpret information for the client: Using family or friends can lead to miscommunication, breaches of confidentiality, or bias. Professional interpreters are preferred to ensure accurate and complete information.

C. Direct attention toward the interpreter when speaking to the client: When using an interpreter, the nurse should maintain eye contact and direct communication to the client, not the interpreter, to foster rapport and respect.

D. Review the facility policy about the use of an interpreter: Reviewing policy ensures that the nurse follows legal, ethical, and professional guidelines for language access services. This is the appropriate first action before arranging or using an interpreter.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about bladder retraining for incontinence. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion, which of the following actions should the nurse take? Select all that apply.

A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse is assessing a client following abdominal surgery. Which of the following findings should the nurse report to the provider?

A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

A nurse is planning care for a client who has terminal cancer and is nearing the end of life. Which the following interventions should the nurse include?

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the follow information should be provided to the client by the provider before signing the form? (Select all that apply.)

A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse make?

A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

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