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 D
Explanation
A. A relapse plan explains how you can be hospitalized if needed. A relapse plan focuses on early symptom recognition and intervention rather than hospitalization. While hospitalization may be necessary in severe cases, the primary goal is to prevent relapse through proactive measures.
B. A relapse plan addresses your living, housing, and working needs. While stable housing and employment are important for recovery, a relapse plan is specifically designed to identify early warning signs and strategies to prevent symptom exacerbation rather than addressing broader social needs.
C. A relapse plan describes how you use coping strategies for living in the community. While coping strategies are included, a relapse plan is more comprehensive, incorporating early symptom detection, medication adherence, and support systems to prevent deterioration.
D. A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse. Recognizing early symptoms of schizophrenia and implementing preplanned interventions can reduce the likelihood of a full relapse, allowing for timely adjustments in treatment and support.
Correct Answer is C
Explanation
A. Lithium toxicity. The AIMS test does not assess lithium toxicity. Lithium toxicity is monitored through serum lithium levels and clinical symptoms such as tremors, nausea, confusion, and ataxia. Severe toxicity can lead to seizures, coma, and organ failure, requiring immediate intervention.
B. Alcohol withdrawal. The AIMS test does not assess alcohol withdrawal. Withdrawal symptoms include tremors, hallucinations, seizures, and autonomic instability. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess symptom severity and guide treatment.
C. Tardive dyskinesia. The AIMS test is used to assess tardive dyskinesia, a movement disorder caused by long-term antipsychotic use. It evaluates involuntary movements of the face, tongue, and extremities, helping clinicians monitor progression and adjust medications to minimize symptoms.
D. Opiate withdrawal. The AIMS test does not assess opiate withdrawal. Symptoms include sweating, agitation, diarrhea, and muscle aches. The Clinical Opiate Withdrawal Scale (COWS) is typically used to assess withdrawal severity and guide opioid detoxification or replacement therapy.
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