How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.

A.

Pressured speech

B.

Disorganized thought process

C.

Excessive spending habits

D.

Hallucinations

E.

Lack of sleep

Answer and Explanation

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A. Bradycardia: Bradycardia is an uncommon response to IV fluid therapy; more frequently, fluid overload can cause tachycardia as the heart attempts to compensate for increased blood volume. Bradycardia would more likely result from other cardiac or neurological issues rather than fluid administration.
B. Weight loss: IV fluid therapy generally results in fluid retention or maintenance of body weight; weight loss is not expected unless there is concurrent fluid loss or other underlying conditions. Monitoring weight gain is important to detect fluid overload rather than weight loss.
C. Distended neck veins: Distended neck veins are a classic sign of fluid volume overload, indicating increased central venous pressure due to excess fluid in the circulatory system. This finding requires prompt intervention to prevent complications such as pulmonary edema or heart failure.
D. Bradypnea: Slow respiratory rate is rarely caused by IV fluids and more commonly indicates neurological impairment, sedation, or respiratory muscle fatigue. It is not a typical adverse effect of fluid therapy and should prompt evaluation for other causes.

Correct Answer is B,A,D,C

Explanation

After donning sterile gloves, the nurse must first lubricate the catheter with sterile saline to reduce friction during insertion. The catheter is then inserted gently until resistance is felt, indicating it has reached the tracheal wall. At this point, it should be slightly withdrawn (1–2 cm) to avoid mucosal damage. Suction is then applied while rotating the catheter to evenly clear secretions from the airway.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register