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
Hallucinations
Disorganized thought process
Lack of sleep
Excessive spending habits
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Rationale:
• Pressured speech: The client demonstrates rapid, loud, and nonstop speech, characteristic of mania. Pressured speech reflects heightened energy, distractibility, and decreased need for rest, all typical of a manic episode. It is not a primary symptom of psychosis, although severe psychotic agitation can sometimes alter speech.
• Hallucinations: The client reports seeing a person who is not present and interacting with them, which is a hallmark of psychosis. These perceptual disturbances indicate impaired reality testing. Hallucinations are less common in purely manic states unless mania is accompanied by psychotic features. Here, the client’s persistent visual hallucinations support a diagnosis of psychosis.
• Disorganized thought process: The client exhibits disorganized and tangential speech, reflecting difficulty organizing thoughts. Disorganization is characteristic of psychotic disorders due to impaired reality testing and cognitive processing. It can also appear in mania, particularly when the client exhibits distractibility, racing thoughts, and pressured speech.
• Lack of sleep: The client has gone at least 2 days without sleeping, a classic sign of mania. Decreased need for sleep with preserved energy is typical in manic episodes. Sleep deprivation alone does not indicate psychosis unless accompanied by hallucinations or delusions.
• Excessive spending habits: The client exhibits impulsive financial behavior, giving away large sums of money and overspending. This risk-taking and poor judgment are hallmark features of mania. Such behaviors are less commonly associated with psychosis unless delusions drive them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Rationale:
A. Cerebrospinal fluid electrophoresis: CSF electrophoresis is used to detect oligoclonal bands, which are indicative of multiple sclerosis (MS). The client’s presentation—fatigue, intermittent muscle weakness, tremors, double vision, and gait disturbances—suggests a demyelinating disorder, making this test appropriate.
B. Paracentesis: Paracentesis is used to evaluate ascites, which is not indicated in this client. There are no signs of abdominal fluid accumulation or liver disease that would warrant this procedure.
C. Bone marrow biopsy: Bone marrow biopsy is used for hematologic disorders such as anemia, leukemia, or other blood dyscrasias. The client’s symptoms do not indicate a primary bone marrow pathology.
D. MRI of brain: MRI is the diagnostic imaging of choice for detecting lesions in the central nervous system consistent with multiple sclerosis. It helps visualize demyelination and correlate it with clinical symptoms.
E. X-ray of abdomen: Abdominal X-ray is not indicated, as the client does not present with abdominal pain, obstruction, or gastrointestinal issues requiring imaging.
Correct Answer is A
Explanation
A. Inspect the skin under the boot every 8 hr: Frequent skin assessment is critical for clients in Buck's traction because the traction boot or straps can cause pressure injuries, skin breakdown, or irritation. Checking the skin every 8 hours allows early detection of redness, sores, or areas of compromised circulation and prevents complications associated with prolonged immobility and pressure.
B. Assess the client's peripheral circulation every 12 hr: Peripheral circulation should be assessed more frequently than every 12 hours, typically every 1–2 hours initially, to detect early signs of neurovascular compromise such as cyanosis, pallor, coolness, or numbness. Waiting 12 hours could delay identification of circulation issues that may lead to tissue damage or compartment syndrome.
C. Ensure the weights are resting on the floor: Traction weights must hang freely to maintain proper alignment and effective traction. Allowing the weights to rest on the floor disrupts the pulling force, reducing traction effectiveness, increasing pain, and potentially worsening fracture displacement.
D. Remove the traction to allow the client to use the bathroom: Buck's traction should not be removed for routine activities such as toileting because interrupting traction can cause misalignment, increased pain, and delayed healing. Alternative methods, such as a bedside commode or urinal, should be used while maintaining traction integrity.
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