A nurse is caring for a client who has a new diagnosis of terminal advanced lung cancer. Which of the following is an expected stage of grief based on the stages of dying?

Rationale:

• Pressured speech: The client demonstrates rapid, loud, and nonstop speech, characteristic of mania. Pressured speech reflects heightened energy, distractibility, and decreased need for rest, all typical of a manic episode. It is not a primary symptom of psychosis, although severe psychotic agitation can sometimes alter speech.

• Hallucinations: The client reports seeing a person who is not present and interacting with them, which is a hallmark of psychosis. These perceptual disturbances indicate impaired reality testing. Hallucinations are less common in purely manic states unless mania is accompanied by psychotic features. Here, the client’s persistent visual hallucinations support a diagnosis of psychosis.

• Disorganized thought process: The client exhibits disorganized and tangential speech, reflecting difficulty organizing thoughts. Disorganization is characteristic of psychotic disorders due to impaired reality testing and cognitive processing. It can also appear in mania, particularly when the client exhibits distractibility, racing thoughts, and pressured speech.

• Lack of sleep: The client has gone at least 2 days without sleeping, a classic sign of mania. Decreased need for sleep with preserved energy is typical in manic episodes. Sleep deprivation alone does not indicate psychosis unless accompanied by hallucinations or delusions.

• Excessive spending habits: The client exhibits impulsive financial behavior, giving away large sums of money and overspending. This risk-taking and poor judgment are hallmark features of mania. Such behaviors are less commonly associated with psychosis unless delusions drive them.

Rationale for correct choices

• Inspect the child’s oropharynx: The child has bright red emesis and visible bleeding in the posterior pharynx, which indicates active post-tonsillectomy hemorrhage. Direct visualization helps confirm the bleeding source and severity. Early inspection supports rapid intervention because post-operative tonsillar bleeding can progress quickly and become life-threatening.

• Obtaining a set of vital signs: Active bleeding and vomiting bright red blood require immediate reassessment of vital signs to detect tachycardia, hypotension, or respiratory compromise. Hemoglobin and hematocrit are already low, increasing the child’s risk for hemodynamic instability. Timely vital signs guide urgent decisions about fluid resuscitation and notifying the provider.

Rationale for incorrect choices

• Offer the child a red popsicle: Providing red-colored fluids can mask ongoing bleeding and delay recognition of hemorrhage. The priority is to assess and stabilize the child with known bleeding, not to offer oral intake. This intervention risks obscuring the color of emesis or oral bleeding.

• Place the child in a supine position: Supine positioning increases the risk of aspiration when bleeding or vomiting is present. The child should be maintained upright to allow drainage and airway protection. Supine positioning does not address the current complication and may worsen respiratory safety.

• Encouraging the child to cough and deep breathe: Coughing can dislodge clots and worsen post-tonsillectomy bleeding. The child already has active bright red bleeding, so stimulating airway pressure would increase hemorrhage risk. This intervention is inappropriate in immediate postoperative bleeding scenarios.

• Requesting a prescription for codeine: Codeine is contraindicated in children after tonsillectomy due to risk of respiratory depression from ultra-rapid metabolism. Pain is mild, and bleeding—not pain—is the priority. Requesting codeine does not address the current danger of hemorrhage.