The nurse is assisting in the care of a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. When collecting data, the nurse should identify that which of the following is characteristic of the client's manifestations?

Depression

Delusions

Hallucinations

Mania

Answer and Explanation

The Correct Answer is D

A. Depression. Depression is typically characterized by low energy, feelings of sadness, and withdrawal from activities. Hyperactivity and pacing are not consistent with depressive symptoms, as individuals with depression often exhibit psychomotor retardation rather than excessive movement.
B. Delusions. Delusions are fixed, false beliefs that are not based on reality, such as paranoia or grandiosity. While delusions can occur in mania, the client's primary symptoms of hyperactivity, pacing, and poor concentration are more indicative of a manic episode rather than delusional thinking alone.
C. Hallucinations. Hallucinations involve sensory perceptions that occur without external stimuli, such as hearing voices or seeing things that are not there. The client’s symptoms do not indicate hallucinations but rather heightened activity levels and distractibility.
D. Mania. Mania is characterized by hyperactivity, excessive energy, rapid speech, and poor concentration. Pacing and an inability to focus during group therapy suggest an elevated mood state, making mania the most appropriate identification of the client’s manifestations.

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Correct Answer is C

Explanation

A. Stimulants. Stimulant intoxication typically causes increased energy, agitation, tachycardia, and paranoia, but it does not usually induce hallucinations to the extent described. While severe stimulant use (e.g., methamphetamine or cocaine) can cause paranoia, the significant perceptual disturbances and visual hallucinations suggest a different category of drugs.
B. Opioids. Opioid intoxication generally leads to central nervous system depression, respiratory depression, pinpoint pupils, and sedation rather than paranoia, hallucinations, and erratic behavior. The described symptoms do not align with opioid use.
C. Hallucinogens. Hallucinogen use, such as LSD or PCP, can cause altered perception, paranoia, visual hallucinations, and erratic behavior. The client’s symptoms—paranoia, visual disturbances, mumbling, and gesturing—are characteristic of hallucinogen intoxication, making this the most likely cause.
D. Anabolic steroids. Anabolic steroid use can lead to mood swings, aggression, and psychotic symptoms in some cases, but it does not typically cause acute hallucinations, paranoia, or perceptual disturbances. The symptoms described do not fit anabolic steroid use.

A. Notify child protective services. B. Suggest the children live with other relatives. C. Encourage the children to visit the psychiatric unit when the client is leaving. D. Offer the client information about a support group for parents.

Correct Answer is D

Explanation

A. "Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.
B. "Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.
C. "Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.
D. "Offer the client information about a support group for parents." Support groups provide a structured environment for clients to share experiences, receive guidance, and develop coping strategies, which can help manage stress and improve parenting skills.

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The nurse is assisting in the care of a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. When collecting data, the nurse should identify that which of the following is characteristic of the client's manifestations?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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