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The nurse continues to care for the client.

Exhibits

Fill in each blank in the following sentence.

The client is most likely experiencing <div id="dropdown-group-1">dropdown</div> as evidenced by the client's <div id="dropdown-group-2">dropdown</div>.
Answer and Explanation

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

Rationale for correct choices:

  • Mania: The client exhibits classic signs of mania, including decreased need for sleep, excessive energy, impulsive spending, grandiosity, pressured and disorganized speech, and poor self-care. These behaviors reflect a manic episode, often seen in bipolar disorder, which requires careful monitoring and intervention.
  • Euphoric mood: The client demonstrates an abnormally elevated and joyous mood, along with inflated self-confidence and excessive sociability. This euphoric mood is a hallmark feature of mania and differentiates it from other psychiatric conditions such as depression or delirium.

Rationale for incorrect choices:

  • Major depressive disorder: This disorder presents with persistent low mood, anhedonia, and decreased energy. The client displays the opposite symptoms, including hyperactivity, elevated mood, and impulsivity, making depression an unlikely diagnosis.
  • Delirium: Delirium is characterized by an acute change in attention, confusion, and disorientation, often fluctuating throughout the day. While the client is disoriented to place, the presence of sustained elevated mood and hyperactivity supports mania rather than delirium.
  • Panic disorder: Panic disorder involves sudden, intense episodes of fear with physical symptoms like palpitations, shortness of breath, and sweating. The client’s presentation is chronic and includes mood elevation and impulsive behaviors, which are inconsistent with panic disorder.
  • Catatonia: Catatonia involves motor immobility, mutism, or extreme negativism. The client is highly active, with constant movement and pressured speech, which is the opposite of catatonic presentation.
  • Anhedonia: Anhedonia refers to the inability to experience pleasure and is a symptom of depression. The client shows excessive pleasure-seeking behaviors, including socializing and impulsive spending, making anhedonia inconsistent with the current presentation.
  • Hypervigilance: Hypervigilance involves heightened alertness and exaggerated startle response, often seen in anxiety or PTSD. The client’s primary features are elevated mood and impulsive behavior rather than persistent vigilance.
  • Magical thinking: Magical thinking involves believing that one’s thoughts or actions can influence unrelated events. While the client reports hallucinations, there is no evidence of magical thinking as the hallucinations do not involve causative beliefs.
  • Alogia: Alogia is a reduction in speech output, typically seen in schizophrenia or severe depression. The client’s speech is pressured, loud, and disorganized, which is opposite to alogia.


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Related Questions

Correct Answer is D

Explanation

A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.

B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.

C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.

D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.

Correct Answer is C

Explanation

A. Assist the family to establish a daily routine: Establishing routines can provide structure, but it is more effective after the nurse has assessed the family’s current functioning and needs following the loss.

B. Refer the family to a grief support group: Referral to support groups is beneficial, but it is not the initial step. Understanding the family’s dynamics and coping capacity should precede external referrals.

C. Determine the roles of individual family members: Assessing each member’s role and function helps the nurse understand how the family is coping and identifies areas of strength and need. This assessment guides appropriate interventions and prioritizes support.

D. Encourage the family to assign specific tasks to individual family members: Assigning tasks is part of restoring structure, but it should follow an assessment of roles and capabilities to ensure tasks are appropriate and achievable.

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