N322 Mental Health Nursing Exam 1 Practice Questions

A school nurse is speaking to the mother of a 16 year old male adolescent. The mother has concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide? A. "His favorite teacher committed suicide a few weeks ago." B. "He has slept 9 hours each night for the past 2 years." C. "He is very religious and attends services twice a week." D. "He spends much of his time with his two school friends."

A. "His favorite teacher committed suicide a few weeks ago." Rationale: Adolescents are at risk for a "copycat" suicide if a peer or a significant role model has recently committed suicide. Adolescents often act impulsively and can be easily frustrated. The fact that an admired person committed suicide is a stressor that could put the adolescent at risk for suicide.

A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client? A. "I will assist you in getting out of bed and getting dressed." B. "You can remain in bed until you feel well enough to join the group." C. "The unit rules state that you may not remain in bed." D. "If you don't participate in your care, you will not get better."

A. "I will assist you in getting out of bed and getting dressed." Rationale: Severely depressed persons have problems with self-care and are easily overwhelmed. A nursing approach that focuses on meeting the client's physiologic and basic needs directly is best. The presence of the nurse conveys that the client is worthy of the nurse's attention and will help the client adjust to the hospitalization.

A nurse is providing care for a client who seems anxious following a recent tragedy. Which of the following statements by the client reflects an adaptive use of sublimation? A. "I will work out in the gym every time I get mad about what happened." B. "I do not have anxiety, and I'm not sure why you think I do." C. "I can't remember anything that happened, but I am okay." D. "I'm not capable of moving past this time in my life."

A. "I will work out in the gym every time I get mad about what happened." Rationale: This represents sublimation, which is dealing with unacceptable feelings or impulses by substituting acceptable forms of expression. This is considered an adaptive defense mechanism, and the use of this can be encouraged by the nurse to assist the client in decreasing anxiety.

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make? A. "I'm glad you called, and I want to send an ambulance to help you." B. "You must have been feeling pretty depressed to do that." C. "Do you know how many pills were in the bottle?" D. "Were you trying to kill yourself by taking an overdose?"

A. "I'm glad you called, and I want to send an ambulance to help you." Rationale: Amitriptyline, a tricyclic antidepressant, is used to treat depression. This therapeutic statement shows the nurse's concern for the client's safety and responds to the client's priority need. Maslow's hierarchy of needs states that the client's physical and safety needs come first. Therefore, the client needs to be evaluated immediately.

A nurse is speaking with the parents of a 4 year old child who has a terminal illness. The parents tell the nurse they have taken their son's name off the list for little league baseball next season. Which of the following responses should the nurse make? A. "It must be frustrating for you to have to cancel an activity your son enjoyed." B. "Baseball can be a dangerous sport for children anyway." C. "You never know. He could be ready for baseball by the spring." D. "Why did you feel you needed to do that at this time?"

A. "It must be frustrating for you to have to cancel an activity your son enjoyed." Rationale: This response demonstrates the therapeutic communication technique of sharing empathy. It is neutral and nonjudgmental and invites further communication and sharing. Asking "why" questions is a nontherapeutic communication technique, and can make the parents defensive and decrease communication between them and the nurse.

A nurse is teaching a group of clients about St. John's wort. Which of the following information should the nurse include in the teaching? A. "St. John's wort can be used to treat mild depression." B. "St. John's wort increases estrogen levels in the body." C. "St. John's wort can reduce the effectiveness of oral contraceptives." D. "St. John's wort can lower prostate-specific antigen levels."

A. "St. John's wort can be used to treat mild depression." Rationale: The nurse should teach that St. John's wort increases the serotonin level of serotonin-enhancing antidepressants, which may place the client at risk for serotonin syndrome.

A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "The courts might require me to discuss confidential information." B. "I am required to provide confidential information to insurance companies." C. "If questioned during a police investigation, I am required to divulge confidential information." D. "I am legally allowed to discuss confidential information with the client's former therapist."

A. "The courts might require me to discuss confidential information."

A nurse is caring for a client who has MDD and is scheduled for ECT. The client's spouse asks the nurse about potential side effects of the ECT. Which of the following responses should the nurse make? A. "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss." B. "Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure." C. "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen." D. "The most common side effects are directly related to the use of anesthesia."

A. "The main side effects are temporary, and may include mild confusion, a headache, and short-term memory loss."

A nurse is teaching a male client who has a depressive disorder about sertraline. Which of the following information should the nurse include in the teaching? A. "This medication may cause an inability to orgasm." B. "You will notice an improvement in mood within 2 to 3 days." C. "A fever is an expected adverse effect of this medication." D. "Sertraline can cause temporary muscle rigidity."

A. "This medication may cause an inability to orgasm."

A nurse is providing teaching to the parents of an adolescent who has a depressive disorder and a new prescription for trazadone. Which of the following information should the nurse include in the teaching? A. "Trazodone can cause suicidal thoughts in adolescents." B. "Expect your child to lose weight while taking trazodone." C. "Your child's symptoms of depression should improve within one week." D. "Trazodone should be taken in the morning to prevent insomnia."

A. "Trazodone can cause suicidal thoughts in adolescents." Rationale: Trazodone includes a black box warning that it may cause suicidal ideation in children and adolescents. Therapeutic effects of trazodone do not occur for 2 to 3 weeks. Trazodone can cause sleepiness and should be taken at bedtime.

A nurse is caring for an older adult client who had a CVA and has left-sided weakness. The client's partner tells the nurse she is worried about the next steps of treatment for her partner. Which of the following responses should the nurse make? A. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable." B. "Your partner is too critical to consider what tomorrow will bring. Let's just concentrate on today." C. "Don't worry. Most clients like your partner start making progress after a few days of rest." D. "You will have to speak to the provider for that information. I can arrange that for you."

A. "We have begun plans to send your partner to a rehabilitation facility as soon as he is stable." Rationale: This response illustrates the therapeutic communication technique of giving information. It directly addresses the partner's concern and demonstrates that discharge and rehabilitation planning begin on admission.

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client? A. A private room in a quiet location on the unit B. A semi-private room with a roommate who has a similar diagnosis C. A private room close to the nursing station D. A seclusion room until the client's activity level becomes more subdued.

A. A private room in a quiet location on the unit Rationale: A private room in a quiet location is ideal for a client with mania. The client may easily become overstimulated by the number of people and activities in a nursing care unit. A private room can be used for time-out during the day and to settle down to sleep at night.

A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding? A. Anhedonia B. Anergia C. Anosognosia D. Akathisia

A. Anhedonia

A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following action should the nurse take? A. Ask the client if she has a plan to commit suicide. B. Recognize the attempt at manipulation and escort the client back to her activity. C. Assist the client to her room and allow her to rest before resuming activity. D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

A. Ask the client if she has a plan to commit suicide. Rationale: The nurse should take seriously all statements regarding suicide. Asking the client if she has a suicide plan is a specific question that the nurse should include when assessing a client who has possible suicidal ideation.

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply.) A. Death of a parent at a young age B. Recent or impending move C. Low parental expectations D. Volunteering at a community center after school E. Sudden decline in school performance

A. Death of a parent at a young age B. Recent or impending move C. Low parental expectations E. Sudden decline in school performance

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply.) A. Diagnosis of schizophrenia B. Age greater than 55 C. Bachelor's degree D. Male gender E. Recent marriage

A. Diagnosis of schizophrenia B. Age greater than 55 D. Male gender

A nurse is preparing to assist with electroconvulsive therapy. Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply.) A. EEG monitor B. Blood pressure monitor C. Ophthalmoscope D. Cardiac monitor E. Portable x-ray machine

A. EEG monitor B. Blood pressure monitor D. Cardiac monitor Rationale: During ECT, the client is monitored with an EEG to track brain wave patterns. The client's blood pressure is monitored to identify changes that can indicate cardiac stress. The client is monitored with continuous telemetry to identify arrhythmias or other changes in the tracing.

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.) A. Irritability B. Euphoria C. Insomnia D. Low self-esteem E. Chronic pain

A. Irritability C. Insomnia D. Low self-esteem E. Chronic pain

A nurse on an acute mental health unit is caring for a client who has MDD. Which of the following interventions is the nurse's priority? A. Monitor for risk of self-harm. B. Administer prescribed antidepressants. C. Encourage adequate fluid intake. D. Assist with activities of daily living.

A. Monitor for risk of self-harm.

A nurse is discussing culturally competent care at a nursing staff in-service. Which of the following information should the nurse include when discussing clients' cultures? A. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care B. Nonverbal communication is important in few cultures C. Culture plays no role in determining when a client will seek medical care D. Nurses should expect clients to adapt to the care provided regardless of culture

A. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care Rationale: Nurses should assess clients and make decisions regarding care based on culture, rather than based on ethnicity or race. Nonverbal communication is important in nearly every culture and carries different meanings in different cultures. A client's culture often determines when and where she will seek medical treatment. Nurses should adapt care to meet the client's needs and demonstrate culturally sensitive care.

A nurse is caring for a client who is terminally ill and exhibiting signs and exhibiting signs of impending death. The client's medical record states that the client is a practicing Roman Catholic. Which of the following nursing actions is appropriate? A. Offer to make arrangements for the Sacrament of the Sick B. Prepare to stay with the client's body after death until family arrives C. Arrange for a member of the client's faith to bathe the body after death D. Post a sign on the client's door stating, "No Talking"

A. Offer to make arrangements for the Sacrament of the Sick Rationale: Practicing Roman Catholics often wish to receive the Sacrament of the Sick from a priest during times of illness or when death is approaching. Clients who practice Judaism, rather than Catholicism, believe that the body should not be left unattended until after the funeral. Clients who practice Islam, rather than Catholicism, believe that an individual from the client's mosque should perform bathing rituals after death. Posting a sign on the client's door is a potential breach of confidentiality. Roman Catholics do not require a quiet room based on beliefs.

A nurse is caring for a client who is to undergo ECT for the treatment of depression. Which of the following actions should the nurse take prior to the scheduled ECT? (Select all that apply.) A. Request an ECG. B. Witness the informed consent. C. Check the client's blood pressure. D. Obtain a serum parathyroid hormone level. E. Obtain a urine specimen.

A. Request an ECG. B. Witness the informed consent. C. Check the client's blood pressure.

A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take? A. Set limits for the relationship B. Promote the use of transference by the client C. Instruct the client on how he should behave D. Engage in friendly interactions with the client

A. Set limits for the relationship Rationale: The nurse should set professional boundaries with the client through limit setting regarding when and where to meet, roles of the relationship, personal space, and other parameters.

A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect? A. Significant change in weight B. Hyperexcitability C. Exaggerated response to stimuli D. Attention seeking behavior

A. Significant change in weight Rationale: A significant change in weight, either loss or gain, is an expected finding of MDD.

A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach? A. Sit with the client and offer simple, direct information. B. Have the client attend group therapy immediately. C. Explain the unit policies to the client and answer any questions he might have. D. Take the client on a tour of the unit and introduce him to all the staff members on duty.

A. Sit with the client and offer simple, direct information. Rationale: Severely depressed clients can have problems with concentration and are easily overwhelmed. A nursing approach that focuses on giving simple information slowly and directly is best for the newly admitted client.

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.) A. Substance use disorder B. Age greater than 45 years old C. Female gender D. Currently married E. Schizophrenia

A. Substance use disorder B. Age greater than 45 years old E. Schizophrenia Rationale: Clients who have a substance use disorder are at a higher risk for suicide. The rate of suicide increases with age and peaks after the age of 45. Clients who have schizophrenia are at a high risk for suicide.

A nurse is teaching a client who has depression about ECT. Which of the following information should the nurse include in the teaching? A. Temporary memory loss is the most common adverse effect of ECT. B. Medications are given to prevent seizure activity during ECT. C. The greatest risk of ECT is brain damage. D. ECT is effective in the treatment of substance use disorders.

A. Temporary memory loss is the most common adverse effect of ECT.

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors? A. The client has borderline personality disorder. B. The client has a parent who has dependent personality disorder. C. The client has a history of bulimia nervosa. D. The client recently received a promotion at work.

A. The client has borderline personality disorder.

A nurse is planning for a newly admitted client who has MDD following the loss of a child. Which of the following goals should the nurse identify as the priority? A. The client makes a contract not to harm herself. B. The client exhibits expected grieving behaviors. C. The client identifies positive qualities about herself. D. The client assumes an active role in her care planning process.

A. The client makes a contract not to harm herself. Rationale: A client who has major depressive disorder might be at risk for self-harm. This goal is the priority because it focuses on client safety.

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? A. The client runs 4 miles outdoors every afternoon. B. The client drinks 2 liters of liquids daily. C. The client eats 2 to 3 gm of sodium-containing foods daily. D. The client eats foods high in tyramine.

A. The client runs 4 miles outdoors every afternoon. Rationale: Strenuous exercise in outdoor heat, which can lead to dehydration, puts the client at risk for lithium toxicity. Mild to moderate exercise will not lead to lithium toxicity, but if the client engages in strenuous exercise during hot weather, she should take care to replace any water and sodium that have been lost through profuse sweating. This also applies to other factors that can cause the client to become dehydrated, such as having diarrhea or taking diuretics.

A client who has major depressive disorder states to the nurse that he and his family would be better of if he were gone. Which of the following is the nurse's priority response? A. "Do you really think your family would be better off without you?" B. "Are you thinking of harming yourself?" C. "Tell me what is happening right now." D. "When did you first start feeling this way?"

B. "Are you thinking of harming yourself?" Rationale: When a client expresses suicidal intent, it is the nurse's priority to determine the seriousness of the client's intent, whether or not he has a plan and the means to follow through with it, and the lethality of the means.

A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about the desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give? A. "Because you are a minor, I have to share any information that I feel is important with your parents." B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care." C. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us." D. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."

B. "I cannot promise that. I must share this information with other members of the team who are responsible for planning your care." Rationale: The nurse should report issues that are potentially life-threatening to the treatment team. Although trust is the hallmark of the nurse-client relationship, confidentiality does not extend to these situations.

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan? A. "I can remember when my hallucinations first began." B. "I know which of my hallucinations trigger a relapse." C. "I record the number of hallucinations I have each day." D. "I will read as much information as I can about schizophrenia."

B. "I know which of my hallucinations trigger a relapse." Rationale: This statement indicates a client's understanding of relapse triggers and is an important component of a relapse prevention plan. Recording the number of hallucinations each day and remembering when they began indicates an understanding of the management of schizophrenia, but does not address a relapse prevention plan. The desire to gain knowledge regarding schizophrenia does not address a relapse prevention plan.

A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following comments should the nurse make? A. "We will call your family in time for them to get here." B. "I wonder if you are fearful of dying alone." C. "I will make sure staff member is in your room at all times." D. "I will tell your family of your concern so that they can be here."

B. "I wonder if you are fearful of dying alone." Rationale: The nurse is verbalizing the client's implied concerns and seeks to validate if this is the client's concern. By telling the family of the patient's concerns, the nurse assumes she understands the client's concerns. This plan may also violate client confidentiality. By saying they will ensure a staff member will be present at all times and saying that the family will have enough time to get to the hospital, the nurse dismisses the client's concerns and gives false reassurances.

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make? A. "It might help you feel better if you talk about it." B. "I'll just sit here with you for a few minutes then." C. "I understand. I've felt like that before, too." D. "Why are you feeling so down?"

B. "I'll just sit here with you for a few minutes then." Rationale: This therapeutic response is an example of offering self. By sitting with the client, the nurse demonstrates caring and concern, and shows the client that the nurse is available if the client wants to talk.

The nurse is providing discharge teaching for a client who has multiple medication prescriptions and must take the medications at specific intervals when at home. Which of the following instructions should the nurse include in the teaching? A. "You really shouldn't change the schedule we established here in the facility." B. "Let's work together to devise a time schedule that is convenient for you on a daily basis." C. "We'll have to talk to your provider about switching to an alternative schedule." D. "It doesn't really matter what time you take your medications as long as you don't skip any doses."

B. "Let's work together to devise a time schedule that is convenient for you on a daily basis." Rationale: This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to work with the client to modify the schedule so that it meets the client's needs at this time.

A nurse is teaching a client who is scheduled for ECT. Which of the following statements should the nurse include in the teaching? A. "You will require a breathing tube during the procedure." B. "There is a small chance you will have memory loss after this procedure." C. "There is little risk of having a seizure during this procedure." D. "You will receive IV or oral contrast prior to this procedure."

B. "There is a small chance you will have memory loss after this procedure." Rationale: Some clients report memory loss for several weeks following the procedure. The nurse should inform the client that this effect usually resolves, but could possibly be permanent.

A nurse is teaching a client who plans to take St. John's wort to treat her depression. Which of the following information should the nurse include in the teaching? A. "You should avoid driving when taking St. John's wort because it can cause doziness." B. "You may experience vivid dreams while taking St. John's wort." C. "St. John's wort may increase your risk of developing oxalate kidney stones." D. "St. John's wort may cause gastrointestinal irritation."

B. "You may experience vivid dreams while taking St. John's wort." Rationale: The nurse should include in the teaching that St. John's Wort can cause the client to have vivid dreams due to the CNS effects.

A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statements should the nurse make? A. "I understand your grief. I lost a baby also." B. "You may hold your baby as long as you want." C. "I have called for the chaplain to come and stay with you." D. "This is for the best. Your baby was very ill."

B. "You may hold your baby as long as you want." Rationale: Holding the newborn is essential because it helps the client confront the reality of the loss and facilitates progression through the grief process.

A nurse is assessing the suicide risk of a group of clients on a mental health unit. Which of the following clients should the nurse identify as having a risk factor for a suicide attempt? A. A client whose family visits him weekly from out of town. B. A client who usually acts impulsively. C. A pregnant female client who is at 6 months gestation. D. A client who attends religious services at the mental health facility

B. A client who usually acts impulsively. Rationale: The presence of Impulsive or aggressive behaviors is a risk factor for suicide. A client who is depressed and/or has suicidal ideation is more likely to attempt suicide if she also demonstrates impulsive behaviors and acts quickly without thinking. Having effective problem-solving and coping skills are both protective factors.

A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take? A. Prepare for gastric lavage due to an extremely elevated lithium level. B. Administer the morning dose of lithium. C. Check the client's medication record to assess whether the client has been refusing her lithium. D. Hold the medication and assess for early manifestations of toxicity.

B. Administer the morning dose of lithium. Rationale: The nurse should administer the lithium dose since a lithium level of 1.0 mEq/L is within the expected initial therapeutic range of 0.8 to 1.3 mEq/L. At a therapeutic level the client might demonstrate adverse effects of lithium, such as a fine hand tremor, thirst, and mild nausea, and the nurse should note if any of these manifestations are present. The nurse should continue to monitor for adverse effects and signs of toxicity, which usually occur at levels of 1.5 mEq/L or higher.

A nurse is planning care for a client who is scheduled to receive ECT. Which of the following medications should the nurse anticipate administering prior to the procedure? A. Diphenhydramine B. Atropine C. Epinephrine D. Fluoxetine

B. Atropine Rationale: Atropine is commonly administered prior to ECT to reduce secretions and protect against vagal stimulation (bradycardia) during the procedure.

A nurse is caring for a client who has MDD and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain that antidepressants often take several weeks to be fully effective. C. Tell the client that the provider will need to change citalopram to a different medication. D. Recommend a sleep study be done on the client.

B. Explain that antidepressants often take several weeks to be fully effective. Rationale: SSRIs are used along with certain anticonvulsant medications in the treatment of bipolar disorder. It can take 4 to 6 weeks before therapeutic effects occur after beginning an antidepressant medication.

A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder? A. Recent history of stressful, positive life events. B. Past history of childhood trauma. C. Being an only child. D. Having elevated levels of serotonin.

B. Past history of childhood trauma.

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms? A. Conversion B. Projection C. Undoing D. Regression

B. Projection Rationale: Projection is a defense mechanism in which the client refuses to acknowledge unacceptable personal characteristics and transfers feelings, thoughts, or traits onto another person. Instead of dealing with his own failures, the client is describing the shortcomings of the course and teacher.

A nurse is caring for a client whose partner died five years ago. Which of the following findings indicates that the client is experiencing maladaptive grief? A. The client joined a bowling league 2 months ago. B. The client has kept his partner's closet untouched since her death. C. The client exercises at a local health facility 3 days each week. D. The client meets his daughter for dinner every week.

B. The client has kept his partner's closet untouched since her death.

A nurse is teaching about ECT with a newly licensed nurse. The nurse should identify that the newly licensed nurse understands the teaching when she states that ECT treats which of the following disorders? A. Narcotic addiction B. Vegetative depression C. Personality disorder D. Eating disorder

B. Vegetative depression

A nurse is leading a family therapy session for a mother, father and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members? A. "If you keep saying that, I will tell everyone what you did last night." B. "She is always bossing me around. Should she do that?" C. "Can you tell me the reason you get upset each time I go to the mall?" D. "Please do not raise your voice at the children. I am the one who left dishes in the sink."

C. "Can you tell me the reason you get upset each time I go to the mall?" Rationale: This is an example of effective or healthy communication. Healthy communication expresses clear, understandable messages between family members. Each family member is encouraged to express his or her own feelings and thoughts. The family member is asking the member who is perceived to be upset to express feelings openly. The communication is clear, understandable, and direct. This promotes an open exchange of feelings and thoughts.

A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following statements indicates a need for further evaluation? A. "I had a great trip to the Smokey Mountains." B. "Going back to work has been okay." C. "I just don't like going to the movies like I used to." D. "I can't wait to have my family together next weekend."

C. "I just don't like going to the movies like I used to."

A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for bupropion. Which of the following statements by the client indicates understanding of the teaching? A. "I may develop a slow heartbeat while taking bupropion." B. "I can drink one glass of wine with dinner each day while taking bupropion." C. "I may not notice a lifting of my mood for at least 2 weeks." D. "I should watch for increased salivation and drooling while taking bupropion."

C. "I may not notice a lifting of my mood for at least 2 weeks." Rationale: Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI). As with other antidepressants, it can take 2 to 4 weeks for therapeutic effects to occur when taking bupropion. The client should be taught to avoid alcohol. Central nervous system depressants, including alcohol, increase the risk for seizures while taking bupropion.

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes and with combed and styled hair. Which of the following responses by the nurse is therapeutic? A. "Everyone feels better after showering." B. "You must be getting better. You look great!" C. "I see you have done some grooming today." D. "Why are you all dressed up today? Is it a special occasion?"

C. "I see you have done some grooming today." Rationale: This response is open-ended, and this response is therapeutic because it offers the client recognition of positive behavior and encourages further discussion.

A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the client indicates understanding of the teaching? A. "I should expect relief from depression within 3 to 4 days." B. "I will take my fluoxetine at bedtime so I can sleep better." C. "I should notify my provider if I develop a skin rash." D. "I will notice an improvement in my sex drive."

C. "I should notify my provider if I develop a skin rash."

A nurse working in suicide prevention is discussing suicide interventions with a newly hired nurse. Which of the following statements indicates the newly hired nurse understands when a tertiary intervention is needed? A. "I should perform screenings to identify clients at risk for suicide." B. "I should recognize the lethality of the suicide plan." C. "I should provide counseling for the family following the suicide of a client." D. "I should provide a safe environment to prevent the client from committing suicide."

C. "I should provide counseling for the family following the suicide of a client." Rationale: Providing counseling for the family following the suicide of a client is an example of tertiary intervention. Following the suicide of a client, family and friends are, themselves, at risk for suicide, and can be helped by therapeutic communication. They may require referral for grief counseling or other supportive measures.

A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates an understanding of the teaching? A. "I need to make a voluntary choice to stop feeling depressed." B. "I can cure my depression by thinking positive thoughts." C. "I will attend psychotherapy to help manage my depression." D. "I will plan on my antidepressant taking three to five days to be effective."

C. "I will attend psychotherapy to help manage my depression."

A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge? A. "Right now, I can't bathe or dress myself, but that's not important." B. "When I get home, I'm going to let the people who put me here know how I angry I am." C. "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts." D. "Taking care of myself is important, but it's okay if I want to take a break and not do anything."

C. "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts." Rationale: This statement verbalizes a willingness to adhere to a medication regimen and a plan for help to avert future crises, both of which support the client's readiness for discharge.

A charge nurse is providing teaching to a staff nurse about assisting the provider with ECT. Which of the following responses by the staff nurse indicates understanding of the teaching? A. "ECT is an effective treatment for personality disorders." B. "I should monitor the client closely for hypotension following ECT." C. "Informed consent should be obtained prior to ECT." D. "It is a myth that clients experience seizures during ECT."

C. "Informed consent should be obtained prior to ECT." Rationale: ECT is effective in the treatment of depression rather than personality disorders. The client is at risk for hypertension, rather than hypotension, following ECT. Clients experience induced seizures during ECT; however, the use of medications limits the severity.

A nurse is caring for a client who is undergoing ECT. Which of the following statements indicates an understanding of the teaching? A. "I will be awake during the procedure." B. "I will undergo treatments for one year." C. "My memory loss will last several minutes after treatment." D. "I will be monitored closely for seizure activity."

C. "My memory loss will last several minutes after treatment." Rationale: During the recovery phase, the nurse should orient the client frequently due to confusion and short-term memory loss that tend to follow ECT. During this time, the nurse should continue to monitor the client's vital signs, mental status, and memory. The client and client's family should understand short-term memory loss, confusion, and disorientation can occur immediately following the procedure and can persist for a few weeks.

A school nurse is talking with a 13 year old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? A. "My parents treat me like a baby sometimes." B. "I haven't gotten my period yet, and all my friends have theirs." C. "None of the kids at this school like me, and I don't like them either." D. "There's a big pimple on my face, and I worry that everyone will notice it."

C. "None of the kids at this school like me, and I don't like them either." Rationale: This comment indicates the client might be at risk for depression, an eating disorder, or self-harm. Therefore, this comment is the priority for the nurse to address.

A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make? A. "I will have your provider discuss the adverse effects with you before the treatment begins." B. "Someone from the American Cancer Society will be here to answer your questions." C. "What is it about the adverse effects that concern you?" D. "I agree. Sometimes the adverse effects can be worse than the disease."

C. "What is it about the adverse effects that concern you?" Rationale: With this response, the nurse takes responsibility for answering the client's concerns rather than passing them to someone else. It also exemplifies the therapeutic communication technique of exploring, as it invites the client to share her concerns.

A nurse is caring for a client who was admitted to the facility in critical condition following a CVA. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make? A. "Perhaps you could call your children to see how they are doing." B. "Don't worry. We'll take good care of your parent while you are gone." C. "You are feeling drawn in two separate directions." D. "There's nothing you can do here. You should go home to your children."

C. "You are feeling drawn in two separate directions." Rationale: This response illustrates the therapeutic communication technique of restatement. This open-ended statement encourages further communication by the son. Suggesting the client call their children illustrates the nontherapeutic communication block of giving advice rather than the therapeutic response of focusing on the son's feelings.

A nurse is providing teaching for a client who has MDD and is seeking voluntary admission to an acute mental health facility. Which of the following statements should the nurse include? A. "You will give up your right to refuse antidepressant medications upon admission." B. "Your provider is required to notify your employer of your admission." C. "You will still need to give informed consent for treatments after admission." D. "You cannot leave the facility until your provider completes a discharge summary."

C. "You will still need to give informed consent for treatments after admission." Rationale: Whether a client is receiving treatment voluntarily or involuntarily, they retain the right to refuse any recommended medications and treatments they do not wish to receive. Informing an employer of an employee's admission without the client's permission is a breach of confidentiality. A client who seeks voluntary admission can leave the facility whenever they no longer wish to receive treatment. The only time the provider can prevent a client from leaving the facility is if it is determined that they plan to harm themselves or others.

A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take? A. Ask the client to create her own schedule of daily activities B. Teach the client to use passive communication when interacting with others C. Determine the client's need for assistance with grooming D. Limit the client's involvement in unit activities

C. Determine the client's need for assistance with grooming Rationale: The nurse should promote problem-solving by helping the client identify situations which can or cannot be controlled. This can help the client deal with unresolved issues.

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident? A. Provide professional counseling for staff members. B. Change policies for staff observation of clients who are suicidal. C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. D. Give the family an opportunity to talk about their feelings.

C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. Rationale: Identifying cues in the client's behavior is the priority intervention when taking the nursing process approach to client care. Assessment is the first step in dealing with a situation.

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take? A. Place metal utensils on the client's meal tray. B. Assign the client to a private room. C. Inspect the client's personal belongings. D. Tuck bedcovers over client's hands and arms.

C. Inspect the client's personal belongings. Rationale: Inspecting the client and his personal belongings is an appropriate intervention to ensure that the client does not have access to potentially harmful objects.

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first? A. Implement the client's behavioral modification plan. B. Document the size and location of the cuts. C. Inspect the cuts for debris. D. Administer a tetanus antitoxin.

C. Inspect the cuts for debris. Rationale: The first action the nurse should take when using the nursing process is to assess the client, therefore inspecting the cuts is the first action the nurse should take.

A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide? A. Premenstrual dysphoric disorder B. Seasonal affective disorder C. Major depressive disorder D. Persistent depressive disorder

C. Major depressive disorder

A nurse in an acute care mental health facility is caring for a client with depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care? A. Encourage family to take the client out of the facility for short periods of time. B. Reward the client for her change in behavior. C. Monitor the client's whereabouts at all times. D. Ask the client why her behavior has changed.

C. Monitor the client's whereabouts at all times. Rationale: Clients who have depression and exhibit a sudden change in behavior are at risk for suicide and suicide precautions should be included in the plan of care. Antidepressant medications generally take 1 to 3 weeks before improvement is seen. A cheerful mood with no signs of a depressive state 3 days after treatment begins might indicate that the client has made a decision to commit suicide.

A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention? A. Administering an anticonvulsant. B. Padding side rails to prevent injury. C. Preparing for artificial ventilation. D. Applying a cooling blanket.

C. Preparing for artificial ventilation. Rationale: Delirium, severe vital sign changes, and apnea may be present in the client who has serotonin syndrome. Preparing for artificial ventilation is the priority intervention when taking the airway, breathing, circulation approach to client care.

A nurse is planning care for a group of clients on a mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment? A. Plan to discuss any topic that is presented B. Focus on client weaknesses to increase adaptation C. Provide continuity of care by assigning the same stuff D. Allow client to determine the boundaries of the nurse-client relationship

C. Provide continuity of care by assigning the same stuff Rationale: Consistent interactions are important in any care setting, but especially in a mental health. This will help clients establish trust and a sense of security.

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy? A. Encouraging client feedback about satisfaction with the facility experience B. Explaining unit rules and policies regarding unacceptable behaviors C. Supporting the client's wish to refuse prescribed medications D. Making sure the client understands expectations for client preparation

C. Supporting the client's wish to refuse prescribed medications Rationale: Supporting the client's wishes is an important component of client advocacy. The first statement represents the ethical concept of fidelity. The second and fourth statements both demonstrate the ethical concept of veracity.

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? A. Recommend a game of table tennis with another client. B. Suggest the client exercise on a stationary bike. C. Take the client outside for a walk. D. Praise the client's efforts to engage in social interaction.

C. Take the client outside for a walk. Rationale: Clients who are experiencing mania are at risk for physical exhaustion; therefore, the nurse should redirect the client to a different activity that will decrease stimulation and slow the client's physical activity expenditure.

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide? A. The client has begun playing basketball with several other clients during the past month. B. The client identifies with problems expressed by other clients. C. The client's behavior has become impulsive in the past few weeks. D. The client states she wants to go home to be with her children and partner.

C. The client's behavior has become impulsive in the past few weeks. Rationale: The presence of impulsive behavior is a primary risk factor for suicide and clients who have mania can act in a manner which is hostile, aggressive, and impulsive.

A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make? A. "I can arrange for a female assistive personnel to do your personal hygiene care." B. "The nurse assigned to care for you is very capable and cares for other women in this situation." C. "Your doctor is a man, so it seems like this should not be a problem." D. "I can review the assignments and arrange for a female nurse to care for you."

D. "I can review the assignments and arrange for a female nurse to care for you." Rationale: In this therapeutic response, the nurse demonstrates empathy by endeavoring to meet the client's request for a female caregiver.

A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? A. "Of course people care. Your family comes to visit every day." B. "Why do you feel that way?" C. "Tell me who you think doesn't care about you." D. "I care about you, and I am concerned that you feel so sad."

D. "I care about you, and I am concerned that you feel so sad." Rationale: This is an open-ended therapeutic statement that focuses on the client's feelings, shows empathy, and allows for further exploration of the client's belief that life is not worth living in order to keep the client safe from suicidal thoughts.

A nurse is teaching a client who has a new prescription for paroxetine. Which of the following statements by the client indicates an understanding of the teaching? A. "I may experience an increased desire to have sex." B. "My blood pressure may increase." C. "I may notice excess saliva." D. "I may not feel like eating as much."

D. "I may not feel like eating as much." Rationale: Anorexia and a decreased appetite are adverse effects of paroxetine.

A nurse in an acute mental health facility is caring for a client who has MDD. Since her admission 3 days ago, she has not put on clean clothes, washed her hair or participated in any of the unit activities. On this day, the nurse observes that she is wearing clean clothes and has combed her hair. Which of the following responses should the nurse make? A. "Oh, I'm so pleased that you finally put on clean clothes." B. "Why did your wear clean clothes and comb your hair today?" C. "Your mood must be lifting because you have on clean clothes and have combed your hair." D. "I see that you have on clean clothes and have combed your hair."

D. "I see that you have on clean clothes and have combed your hair." Rationale: This comment provides recognition of the client's behavior and efforts at self care without making a value judgment or offering approval. This is a therapeutic communication technique.

A nurse is reinforcing teaching with an older adult client who has MDD and a prescription for nortriptyline 25 mg daily. Which of the following client statements indicates understanding of the teaching? A. "I should take my nortriptyline before breakfast." B. "I can no longer eat pepperoni pizza." C. "I will avoid drinking caffeinated beverages." D. "I should sit on the side of the bed before standing up in the morning."

D. "I should sit on the side of the bed before standing up in the morning." Rationale: Nortriptyline is a TCA. It blocks reuptake of norepinephrine and serotonin in the synaptic space, intensifying the effects of these neurotransmitters. Orthostatic hypotension is a potential complication of TCAs. Clients should be instructed to change positions slowly and to sit and lie down if symptoms occur. If a significant decrease in blood pressure is noted in the hospitalized client, the medication should be held, and the provider should be notified.

A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should the nurse make? A. "Antidepressants are not your solution, but this therapy group is." B. "I notice you keep clenching your fists. This needs to stop." C. "You need to work hard on resolving conflict with those closest to you." D. "Let's discuss what you mean when you say that you cannot ever return to work."

D. "Let's discuss what you mean when you say that you cannot ever return to work." Rationale: This is an example of clarification, which is a therapeutic communication technique. Clarification asks the group member to expand and clarify what he/she means so as to create a better understanding during the group session.

A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control method the nurse would recommend. Which of the following responses should the nurse make? A. "It's your choice, of course, but birth control pills are the most reliable." B. "Your provider usually recommends a diaphragm and spermicidal cream." C. "I'd consider an intrauterine device. You won't have to worry about pregnancy." D. "Let's talk about the available options and go from there."

D. "Let's talk about the available options and go from there." Rationale: This response illustrates the therapeutic communication technique of formulating a plan of action. It demonstrates the nurse's willingness to provide information so that the client can make an informed choice that will meet her needs at this time.

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition? A. "Postpartum depression usually begins 48 hours after childbirth." B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." C. "The most common manifestation of postpartum depression is harming the infant." D. "Postpartum depression is more likely to occur in women who have a history of depression."

D. "Postpartum depression is more likely to occur in women who have a history of depression."

A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make? A. "Perhaps you should discuss this with your physician." B. "Of course you aren't going to die, at least not in the immediate future." C. "I recommend you exercise daily and avoid smoking to decrease your risk." D. "Tell me more about these fears of dying from a heart attack."

D. "Tell me more about these fears of dying from a heart attack." Rationale: With this response, the nurse uses the therapeutic communication technique of exploring to encourage further communication about the client's feelings.

A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make? A. "Using nontraditional treatments is not a good idea. I'd rather you avoid that route." B. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice." C. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you." D. "Tell me more about your concerns about taking chemotherapy."

D. "Tell me more about your concerns about taking chemotherapy." Rationale: Asking the client to talk more about her fears and her concerns encourages communication. It is an example of the therapeutic communication technique of exploring.

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response? A. "Your husband is making really good progress." B. "Crying helps us let things out and we feel better." C. "Did your husband say something to upset you?" D. "Tell me what is concerning you."

D. "Tell me what is concerning you." Rationale: This therapeutic response uses the communication tool of clarification. This response encourages further communication and expression of feelings.

A nurse is caring for a client admitted to a mental health facility who asks, "Can I refuse the ECT treatment scheduled for tomorrow?" Which of the following should be the nurse's response? A. "You have given signed consent for the treatments after they were explained to you." B. "You will feel better after the course of treatments." C. "You can refuse them, but the provider believes they are necessary." D. "You have the right to refuse even though the consent form has been signed."

D. "You have the right to refuse even though the consent form has been signed." Rationale: Informed consent is a communication between provider and client regarding the risks and benefits of treatment. The client authorizes the treatment with a witnessed signature to undergo the medical intervention. The client has the right to refuse or delay treatment, even though the informed consent has been signed.

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate? A. "You are being unreasonable, and I will not call your doctor at this hour." B. "Go back to your room, and I'll try to get in touch with your doctor." C. "I can't call a doctor in the middle of the night unless it's an emergency." D. "You must be very upset about something."

D. "You must be very upset about something." Rationale: This therapeutic response allows the nurse to show empathy for the client's feelings. The response is also open-ended, which allows for further communication and encourages the client to clarify the situation.

A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make? A. "You should call your boss and ask i you can have your job back." B. "I don't understand why your partner would upset you with news like that." C. "There really isn't much you can do about that until you are discharged." D. "You must feel very concerned and disappointed by that information."

D. "You must feel very concerned and disappointed by that information." Rationale: This is a therapeutic response and an open-ended empathetic statement that encourages the client to talk. The other 3 statements are nontherapeutic responses and do not address the client's feelings.

A nurse is caring for a client who has MDD and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make? A. "You have a great deal to live for." B. "It's not unusual for depressed people to feel that way." C. "Why do you feel you are worthless?" D. "You've been feeling that your life has no meaning."

D. "You've been feeling that your life has no meaning." Rationale: This open-ended statement uses the communication tool of empathy and addresses the client's feeling of worthlessness. This therapeutic response communicates to the client that the nurse was listening, and it will encourage the client to talk further about personal feelings.

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority? A. Lock the doors to the unit and secure windows so they cannot be opened. B. Provide the client with plastic eating utensils for meals. C. Remove any objects from the client's environment that could be used for self-harm. D. Assign a staff member to stay with the client at all times.

D. Assign a staff member to stay with the client at all times. Rationale: The greatest risk to this client is self-injury during unsupervised time; therefore, the nurse should identify the priority action is to assign a staff member to stay with the client at all times. The staff member can monitor all of the client's behaviors and actions and prevent the client from harming herself.

A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? A. Being married B. Pregnancy C. Male gender D. Chronic illness

D. Chronic illness Rationale: Having a medical illness, especially one that is chronic, is a primary risk factor for depression.

A nurse educator is discussing community mental health with a group of nursing students. Which of the following sites should the educator identify as a source of secondary prevention? A. Day care center B. Outpatient rehabilitation center C. Community recreational center D. Crisis center

D. Crisis center Rationale: A crisis center, which has the goal of early detection and treatment of mental health disorders, is an example of secondary public health prevention.

A nurse is assessing a client who is taking bupropion. The nurse should recognize which of the following findings as an indication that the medication is effective? A. Increased weight gain B. Increased urinary output C. Decreased sexual function D. Decreased urge to smoke

D. Decreased urge to smoke Rationale: Bupropion is an antidepressant, also used for smoking cessation.

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take? A. Tell the client that it is unlikely that he has bone cancer B. Ask the client why he thinks the pain isn't a result of hiking C. Suggest genetic testing so the client can understand his risks D. Explain that the provider will see him and determine a course of action

D. Explain that the provider will see him and determine a course of action Rationale: This response illustrates the therapeutic communication technique of focusing the client on the usual course of action that must precede drawing any conclusions about the cause of the client's pain.

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete every day tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care? A. Discourage rest periods during the daytime. B. Instruct family to avoid visiting during mealtimes. C. Offer three or four large meals daily. D. Give the client extra time to communicate needs.

D. Give the client extra time to communicate needs. Rationale: Clients who have vegetative signs of depression have slowed thought processes and might take extra time to reply to questions or to verbalize thoughts. The nurse should display patience and give the client extra time to communicate.

A nurse is caring for a new client who exhibits manifestations of a major depressive episode. The provider states that she wants to rule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions? A. Pancreatitis B. Cholecystitis C. Tuberculosis D. Hypothyroidism

D. Hypothyroidism Rationale: The expected findings of hypothyroidism, including changes in weight, sleep disturbances, decreased energy, and changes in thought processes, mimic those of a major depressive episode.

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention? A. Providing support for family and friends following a suicide B. Identifying individuals who are at higher risk for attempting suicide C. Recognizing the warning signs of suicide D. Performing life-saving measures following a suicide attempt

D. Performing life-saving measures following a suicide attempt Rationale: The first statement is an example of tertiary intervention. The second and third statements are both examples of primary intervention.

A nurse is caring for a client who begins to yell and scream at staff members. Which of the following should be the nurse's priority action? A. Administer haloperidol IM to the client B. Engage the client in an activity C. Move the client to a seclusion room with continuous observation D. Say to the client, "I can tell that you are upset."

D. Say to the client, "I can tell that you are upset." Rationale: The nurse's immediate priority when faced with a client who is potentially violent is to maintain safety while preventing the behavior from escalating. This therapeutic communication helps defuse anger and offers understanding and support. This statement demonstrates the nurse's desire to help the client while listening.

A nurse on an inpatient mental health unit is caring for a client who has MDD and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status? A. Enroll the client in a nutritional class on the unit. B. Weigh the client at the same time every morning. C. Ask provider to arrange a consultation with the facility chaplain. D. Sit with the client during meals and snacks.

D. Sit with the client during meals and snacks. Rationale: A change in appetite is a major symptom of depression. Being present during meals and snacks to support and encourage the client is an appropriate nursing intervention that might help the client at this time.

A nurse is caring for a client who has MDD. Which of the following findings should the nurse expect? A. A dismissal of past failures B. Psychomotor agitation C. An increase in energy D. Sleep disturbances

D. Sleep disturbances

A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care? A. Encouraging decision-making B. Giving the client choices of activities C. Playing a game of chess with the client D. Spending time sitting with the client

D. Spending time sitting with the client Rationale: This option uses the therapeutic communication tool of being silent. Because clients who have depression frequently have suicidal tendencies, spending time with the client will provide for safety. Depression also involves diminished self-esteem, and spending time with the client conveys that the client is worth the nurse's time and attention.

A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day, and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior which of the following defense mechanisms? A. Repression B. Splitting C. Sublimation D. Undoing

D. Undoing Rationale: The nurse correctly identifies this as an example of undoing which is the attempt to make up for or reverse prior behavior. Sublimation is an unconscious mechanism of substituting an unacceptable impulse with one that is acceptable. Splitting is the inability to combine both positive and negative qualities of an individual. Repression is an unconscious forgetting of an unpleasant or unwanted experience or emotion.