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

Hallucinations

Lack of sleep

Pressured speech

Excessive spending habits

Disorganized thought process

Answer and Explanation

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

Rationale:

Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.

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Free Nursing Study Resources

Correct Answer is B,D,C,A

Explanation

Rationale:

B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.

D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.

C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.

A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.

A. "Refrain from doing any exercises until your symptoms show improvement." B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear." C. "Use your short-acting beta agonist inhaler before exercising." D. "It is safe to exercise if your peak flow meter measures in the red zone."

Correct Answer is C

Explanation

Rationale:

A. "Refrain from doing any exercises until your symptoms show improvement.": Completely avoiding exercise is not necessary for most people with asthma and can negatively impact cardiovascular health. The goal is to control symptoms so that safe activity is possible.

B. "Use your long-acting beta agonist inhaler after exercise-induced symptoms appear.": Long-acting beta agonists are used for maintenance therapy, not for quick relief. They are not appropriate for immediate symptom control before or after exercise.

C. "Use your short-acting beta agonist inhaler before exercising.": Short-acting beta agonists, such as albuterol, can be taken 5–20 minutes before exercise to prevent exercise-induced bronchospasm. This is the recommended approach for clients with exercise-triggered asthma.

D. "It is safe to exercise if your peak flow meter measures in the red zone.": The red zone indicates severe airway narrowing and poor asthma control, requiring immediate medical attention. Exercise in this state could worsen symptoms and lead to respiratory distress.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,D,C,A

Explanation

A nurse in a provider's office is caring for a client who has asthma and reports that the manifestations get worse while exercising. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

The nurse continues to care for the client. Exhibits A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client

A charge nurse is delegating tasks for a group of clients on a medical surgical unit. Which of the following tasks should the nurse delegate to the assistive personnel?

A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in?

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to deal with stress. Which of the following actions should the nurse take to assist the client in maintaining self-control of the behavior?

A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings should the nurse report to the provider?

A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

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