The nurse is assisting in the care of a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. When collecting data, the nurse should identify that which of the following is characteristic of the client's manifestations?
Depression
Delusions
Hallucinations
Mania
The Correct Answer is D
A. Depression. Depression is typically characterized by low energy, feelings of sadness, and withdrawal from activities. Hyperactivity and pacing are not consistent with depressive symptoms, as individuals with depression often exhibit psychomotor retardation rather than excessive movement.
B. Delusions. Delusions are fixed, false beliefs that are not based on reality, such as paranoia or grandiosity. While delusions can occur in mania, the client's primary symptoms of hyperactivity, pacing, and poor concentration are more indicative of a manic episode rather than delusional thinking alone.
C. Hallucinations. Hallucinations involve sensory perceptions that occur without external stimuli, such as hearing voices or seeing things that are not there. The client’s symptoms do not indicate hallucinations but rather heightened activity levels and distractibility.
D. Mania. Mania is characterized by hyperactivity, excessive energy, rapid speech, and poor concentration. Pacing and an inability to focus during group therapy suggest an elevated mood state, making mania the most appropriate identification of the client’s manifestations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inappropriate guilt is a common symptom of depression, but it does not involve false beliefs about being targeted. Clients with major depressive disorder may feel excessive guilt, but this differs from the fixed, false beliefs seen in delusions.
B. Mania is characterized by elevated mood, impulsivity, and hyperactivity rather than paranoid thoughts. While manic episodes may include grandiose delusions, the belief that a government agency is attempting to capture the client aligns more with persecutory delusions.
C. Delusions are fixed, false beliefs that persist despite evidence to the contrary. The client’s statement suggests a persecutory delusion, which is commonly seen in psychotic disorders, including severe depression with psychotic features.
D. Confusion involves disorganized thinking, memory impairment, or difficulty understanding surroundings, often seen in delirium or cognitive disorders. While delusions can contribute to disorganized thoughts, they are distinct from general confusion.
Correct Answer is C
Explanation
A. "Do you need any more resources or information?" This question focuses on offering additional resources rather than encouraging the client to explore their emotions. While it is useful for providing support, it does not promote self-reflection or invite the client to clarify their feelings. Therapeutic communication should aim to encourage deeper discussion rather than just addressing practical needs.
B. "Do you understand your next step in treatment?" Although this question ensures the client comprehends their treatment plan, it does not foster emotional expression or self-awareness. Understanding the next steps in care is important, but therapeutic communication should focus on exploring the client’s internal experiences rather than just confirming information. Encouraging open-ended reflection is more effective for clarifying emotions.
C. "You feel like you have the support needed to be successful." This statement encourages self-reflection and allows the client to clarify their feelings about their support system. It promotes therapeutic communication by inviting the client to assess their emotional needs and level of confidence. Open-ended statements like this help build trust and provide insight into the client’s concerns and perceptions.
D. "Tell me what kind of coping skills you have." While this question assesses the client's coping strategies, it does not directly facilitate emotional clarification. Asking about coping skills is useful for intervention planning, but it does not specifically address the client’s feelings. A more effective therapeutic approach would involve asking how the client feels about their ability to manage stress.
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