The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Lack of sleep

Pressured speech

Disorganized thought process

Excessive spending habits

Hallucinations

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Lack of sleep: Decreased need for sleep is a core feature of mania, where individuals may go days with minimal rest and still appear energetic or overly active. It is not a defining feature of psychosis, though it may occur secondarily.
Pressured speech: Pressured, rapid, and difficult-to-interrupt speech is strongly associated with mania, reflecting accelerated thought processes and elevated mood. It is uncommon in psychosis unless mania and psychotic features coexist.
Disorganized thought process: This is a hallmark of psychosis, often seen in disorders like schizophrenia. It includes loose associations, tangentiality, and difficulty organizing ideas, and can impair communication significantly.
Excessive spending habits: Engaging in impulsive or risky financial behaviors is a classic symptom of mania, often driven by grandiosity or impaired judgment. This behavior is not typical of psychosis unless mania is also present.
Hallucinations: Perceptual disturbances such as seeing or hearing things that are not present are definitive features of psychosis. While they can occur in severe mania with psychotic features, they are primarily linked to psychotic disorders.

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Correct Answer is C

Explanation

A. "You should make sure your partner takes the prescribed medication." While medication adherence is important, this response shifts the focus to advice-giving rather than exploring the partner’s emotions or current experience, which limits therapeutic communication.
B. "You did the right thing by bringing your partner in for treatment." Although supportive, this statement closes off the conversation and doesn’t invite the partner to share more about their feelings or the situation at home.
C. "Can you talk about what was happening with your partner at home?" This open-ended, therapeutic response encourages the partner to express their thoughts and emotions, facilitating a better understanding of the client’s condition and the impact it has had on the family.
D. "Why do you think your partner's symptoms are progressing so quickly?" Asking “why” can feel accusatory or put the partner on the defensive. It may also imply blame, which is not helpful in building trust or gathering therapeutic insight.

A. Place the tip of the thermometer under the center of the infant's axilla B. Pull the pinna of the Infant's ear forward before inserting the probe. C. Insert the oral thermometer in front of the infant's tongue. D. Insert the probe 3.8 cm (15 in into the infant's rectum

Correct Answer is A

Explanation

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

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The nurse continues to care for the client. Exhibits For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?

Correct Answer is C

Explanation

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

A community health nurse is collaborating with local organizations to plan educational programs for at-risk populations. Which of the following programs should the nurse implement to reach populations in the community that are at increased risk for testicular cancer?

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?

A nurse is teaching a client who has a history of genital herpes and is at 32 weeks of gestation. Which of the following statements should the nurse include in the teaching?

A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is providing preoperative teaching to a client about promoting circulation during the postoperative period. Which of the following instructions should the nurse include?

A nurse is discussing effective communication techniques for a client who has visual impairment with a newly licensed nurse. Which of the following statements by the nurse indicates an understanding of the teaching?

The nurse continues to care for the client.

Exhibits

For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.