The nurse continues to care for the client
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
Pressured speech
Disorganized thought process
Excessive spending habits
Hallucinations
Lack of sleep
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
- Pressured speech is a hallmark of mania, reflecting heightened psychomotor activity and accelerated thought processes. It often overwhelms conversation partners and makes logical communication difficult. This symptom reflects the individual’s racing mind and inability to filter or regulate their verbal output, often seen in manic episodes.
- Disorganized thought process is seen in both psychosis and mania, but manifests differently in each. In psychosis, it is often due to a breakdown in logical thinking or connection to reality. In mania, it reflects flight of ideas, rapid topic shifting, and distractibility. The presence of both symptoms indicates overlapping features.
- Excessive spending habits are consistent with manic behavior, often driven by grandiosity and poor judgment. Clients in a manic state may feel invincible or overly generous, leading them to make irrational financial decisions. These behaviors can result in significant personal or financial consequences, including debt or loss of savings.
- Hallucinations are perceptual disturbances where individuals see, hear, or feel things that are not present, primarily associated with psychosis. Auditory hallucinations, like hearing voices or unseen persons, are especially common. This indicates a loss of reality testing, which is central to diagnosing psychotic disorders.
- Lack of sleep without fatigue or distress is a key feature of mania, often preceding or accompanying a manic episode. Unlike insomnia in depression or anxiety, clients with mania may report feeling energetic and productive. The sleep deficit contributes to cognitive and emotional instability seen in manic phases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased temperature: Vomiting and diarrhea usually cause dehydration, but they do not typically lower body temperature. Infants may have a normal or slightly elevated temperature if an infection is present.
B. Oliguria: Oliguria, or reduced urine output, is a key sign of dehydration in infants. Fluid loss from vomiting and diarrhea leads to decreased kidney perfusion, causing the kidneys to conserve water and produce less urine.
C. Bulging anterior fontanel: A bulging anterior fontanel indicates increased intracranial pressure and is not a sign of dehydration. In contrast, dehydration often causes a sunken fontanel due to decreased fluid volume.
D. Hypertension: Dehydration usually causes low blood pressure in infants because of decreased circulating blood volume. Hypertension is not expected in this situation and would suggest a different underlying issue.
Correct Answer is C
Explanation
A. A client who consumes all the food from their meal tray: Eating a full meal is generally positive and does not require immediate reporting unless related to specific dietary restrictions or concerns.
B. A client who requests assistance to use the bedside commode: Requesting help to use the commode is expected and can be managed by the assistive personnel without urgent nurse notification.
C. A client who has a prescription for compression stockings and did not receive them: Compression stockings prevent deep vein thrombosis and promote circulation. Not receiving them as prescribed is a safety concern that requires prompt nurse awareness and intervention.
D. A client who requests to sit in the bedside chair while watching TV: This is a normal, non-urgent request that the assistive personnel can usually handle without needing to notify the nurse immediately.
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