The nurse continues to care for the client.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is most likely experiencing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Rationale for Correct Choices:
- Mania is characterized by an abnormally elevated, expansive, or irritable mood accompanied by increased energy or activity. This client’s obsessive cleaning, excessive spending, sleeplessness, pressured speech, and overly joyous behavior strongly support a manic episode.
- Euphoric mood refers to an exaggerated feeling of well-being or elation not consistent with the client's circumstances. It often presents in mania alongside impulsivity and grandiosity, such as the client’s obsession with hosting parties and giving away money without regard for consequences.
Rationale for Incorrect Choices:
- Delirium: Typically presents with fluctuating consciousness, acute onset confusion, and disorganized thinking often due to a medical cause. The client is alert and oriented to person and time, which is inconsistent with the inattention and acute cognitive changes of delirium.
- Catatonia: Characterized by motor immobility, extreme negativism, mutism, or stupor. The client displays hyperactivity and pressured speech, which are the opposite of the psychomotor retardation seen in catatonia.
- Panic disorder: Involves sudden onset of intense fear with physical symptoms such as palpitations, chest pain, or shortness of breath. It lacks the prolonged mood elevation, impulsivity, and grandiosity observed in this case.
- Major depressive disorder: Presents with persistent sadness, fatigue, anhedonia, and social withdrawal. The client’s symptoms of increased activity, grandiosity, and reduced need for sleep do not align with depression.
- Alogia: Refers to poverty of speech or reduced speech output, often associated with schizophrenia or severe depression. This contrasts with the client’s pressured and excessive speech.
- Magical thinking: Involves believing one’s thoughts can influence the physical world, often seen in psychotic disorders or schizotypal personality disorder. The client describes hallucinations, but no evidence of magical thinking is present.
- Hypervigilance: Describes excessive alertness or scanning for threats, commonly associated with anxiety or PTSD. The client’s symptoms point to elevated mood and disinhibition, not heightened fear or threat perception.
- Anhedonia: A core symptom of depression, characterized by a loss of interest or pleasure in activities. The client’s increased goal-directed activity and enjoyment in planning events contradict this finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Use condoms with a petroleum-based lubricant: Petroleum-based lubricants can degrade latex condoms, increasing the risk of breakage and HIV transmission. Water- or silicone-based lubricants are recommended to preserve condom integrity.
B. Buy disposable dishes for daily use: HIV is not transmitted through casual contact such as sharing dishes or eating utensils. This practice is unnecessary and may contribute to stigma and isolation for individuals living with HIV.
C. Clean blood-contaminated surfaces with bleach: Bleach is effective in inactivating HIV on surfaces. A solution of 1:10 bleach to water is recommended for cleaning any area contaminated with blood or body fluids to reduce transmission risk.
D. Wash soiled clothes in cold water: Cold water is less effective at killing pathogens. Hot water and standard laundry detergent are recommended for properly cleaning clothing contaminated with blood or body fluids.
Correct Answer is C
Explanation
A. Instruct the client on the use of esophageal speech: Esophageal speech is a technique used after laryngectomy and is not relevant for managing xerostomia caused by radiation therapy to the mandible.
B. Suggest rinsing his mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can further dry and irritate the oral mucosa, worsening xerostomia symptoms, so this is not appropriate.
C. Provide humidification of the room air: Increasing humidity helps keep the mucous membranes moist, relieving dry mouth symptoms and providing comfort for clients experiencing xerostomia after radiation therapy.
D. Offer the client saltine crackers between meals: Dry, salty foods like saltine crackers can exacerbate dry mouth and discomfort, so this recommendation is not appropriate for xerostomia management.
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