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A nurse on an inpatient mental health unit is caring for a client.
Exhibits
Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis

Client's chief complaint

Client's job performance history

Client's relationships with family and friends

Client's copying nurses words

Client's statement about their mother

Client's speech pattern

Answer and Explanation

Correct Answer : A,D,E,F

Rationale:

A. Client's chief complaint: Hearing voices is an auditory hallucination, which is a hallmark positive symptom of schizophrenia. Hallucinations reflect a distortion of reality and are typically responsive to antipsychotic treatment.

B. Client's job performance history: Poor job performance reflects functional decline, which is a negative symptom (e.g., avolition or anhedonia), not a positive one. It indicates loss of normal function rather than distortion.

C. Client's relationships with family and friends: Social withdrawal is another negative symptom, reflecting a lack of interest or emotional engagement. Positive symptoms are additions to normal experience, not losses like this.

D. Client's copying nurses' words: Repeating others’ words is known as echolalia, a disorganized thought manifestation commonly seen in schizophrenia. It indicates impaired cognitive processing and communication.

E. Client's statement about their mother: The delusional belief that their mother is trying to kill them represents a paranoid delusion, a classic positive symptom. Such fixed false beliefs are unrelated to reality and resistant to logic.

F. Client's speech pattern: Unclear, jumbled, and disorganized speech reflects disorganized thinking, another positive symptom of schizophrenia. This makes coherent communication and goal-directed behavior difficult.

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Correct Answer is A

Explanation

Rationale:

A. Administer diuretics: The client's symptoms, moist lung sounds, bounding pulse, elevated blood pressure, and pitting edema indicate fluid volume overload. Administering prescribed diuretics is the priority intervention to rapidly reduce intravascular and interstitial fluid volume and relieve pulmonary congestion.

B. Limit the client's fluid intake: Fluid restriction helps manage ongoing fluid retention but does not address the immediate concern of volume overload. It is a supportive measure rather than the initial priority in acute decompensated heart failure.

C. Insert an indwelling urinary catheter: While catheterization may help monitor output, it does not treat the underlying fluid excess. Inserting a catheter without addressing the fluid accumulation first does not provide immediate symptom relief.

D. Place the client on a low-sodium diet: A low-sodium diet is important for long-term management of heart failure, but it does not provide the prompt fluid removal needed in this acute situation. Immediate diuresis is necessary to reduce cardiac workload and respiratory distress.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

Reye's syndrome: The toddler's worsening condition including vomiting, lethargy, and altered consciousness after a viral illness (influenza A) is consistent with Reye’s syndrome, which affects the liver and brain. The progression from mild viral symptoms to neurologic decline without respiratory compromise further supports this diagnosis.
Aspirin administration: Giving aspirin during a viral illness in children is a well-known precipitant of Reye’s syndrome. The caregivers' report of alternating aspirin with acetaminophen confirms the exposure necessary to trigger the condition in a susceptible child.

Rationale for Incorrect Choices:

Gastroenteritis: While vomiting is a feature of gastroenteritis, the absence of diarrhea and the presence of neurologic changes like lethargy and poor responsiveness make this unlikely. Additionally, the clear vomiting and lack of fluid intake without prior GI focus suggest another etiology.
Bronchitis: Bronchitis typically causes a productive cough with wheezing, chest discomfort, and possible fever. This toddler's lungs are clear with a nonproductive cough, and neurologic signs are not typical of bronchitis.
Acetaminophen administration: Acetaminophen is safe and commonly used to treat fever in toddlers. It is not associated with hepatic encephalopathy or neurologic complications seen in this scenario.
Oseltamivir administration: Though oseltamivir may cause gastrointestinal side effects like nausea or vomiting, it does not explain the altered mental status and lethargy. It is also unlikely to cause such a significant clinical deterioration on its own.

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A nurse on an inpatient mental health unit is caring for a client.Exhibits Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has heart failure. The client has moist lung sounds, bounding pulse, increased blood pressure, and pitting peripheral edema. Which of the following is the nurse's priority intervention?

Correct Answer is A

Explanation

A nurse is caring for a toddler in the outpatient setting. Exhibits Complete the following sentence by using the lists of options. The nurse recognizes the toddler has likely developed dropdown due to dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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A nurse on an inpatient mental health unit is caring for a client.
Exhibits
Select 4 findings the nurse should identify as positive manifestations of the clients diagnosis