The nurse continues to care for the client.
Fill in each blank in the following sentence.
The client is most likely experiencing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","G"]
Explanation
Rationale for correct choices:
- Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
- Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
- Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
- Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
- Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.
Rationale for incorrect choices:
- Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
- Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.
Correct Answer is D
Explanation
A. Provide the client with periods of alone time for reflection on their behavior: While reflection can be helpful, unsupervised alone time may increase the risk of relapse in clients with alcohol use disorder and does not actively promote self-control.
B. Discuss strategies with the client to reduce alcohol consumption gradually: Gradual reduction is not always safe due to the risk of withdrawal complications. Abstinence under supervision is the recommended approach for alcohol use disorder.
C. Have the client's partner assume responsibility for monitoring the client's alcohol intake: Delegating responsibility to a family member undermines the client’s autonomy and does not foster personal self-control or coping skills.
D. Give positive feedback to the client for using adaptive coping strategies: Reinforcing the use of healthy coping mechanisms encourages self-control, builds confidence, and promotes continued use of adaptive strategies to manage stress without relying on alcohol.
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