PrepU Chapter 16 and 17
A client diagnosed with bipolar disorder is admitted to an inpatient psychiatric facility with acute mania and threats of attacking others in the household. Which would be the priority?
Ensuring safety
A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client? Exploring the grief and loss issues concerning the baby's death. Encouraging the client to express feelings of isolation following the recent immigration. Encouraging attendance at group cognitive-behavioral therapy on the unit. Ensuring that the client is not permitted to use anything that would be potentially dangerous.
Ensuring that the client is not permitted to use anything that would be potentially dangerous.
The nurse is assessing a client with schizophrenia who has a history of successfully managing the client's symptoms. The client has few social activities and speaks in a flat tone when interacting with others. Currently the client is experiencing active hallucinations and social withdrawal. The nurse identifies improved social skills as an important therapeutic goal. How should the nurse implement this plan?
Enter the client in a social skills training program when acute psychosis subsides.
A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer? Escitalopram Venlafaxine Maprotiline Phenelzine
Escitalopram
A client diagnosed with schizoaffective disorder and severe depression is being treated with antipsychotic medications. The client tells the nurse about difficulty with self-care activities. With which intervention should the nurse respond? Gain assistance from family members. Contact the physician for a change in medications. Establish a routine and set goals. Outline the side effects of the medications.
Establish a routine and set goals.
Average affect and activity
Euthymic mood
How often must clients receiving clozapine get white blood cell counts drawn? Every week for the first 6 months Every 3 months Every 6 months Every year
Every week for the first 6 months
The nurse suspects that a client is experiencing a brief psychotic episode based on what? Select all that apply. Gradual onset of symptoms Evidence of hallucinations Intense changes in affect Mild confusion Recent life stressor
Evidence of hallucinations Intense changes in affect Recent life stressor
A client is diagnosed with schizoaffective disorder. Which would the nurse identify as supporting this diagnosis?
Evidence of hallucinations and delusions accompanied by major depression
After several visits to the primary care provider, a client has been diagnosed with depression. Within the context of the behavioral theorists' beliefs about this disorder, which factors may underlie the client's diagnosis? Exaggerated response to stressful life event Irrational beliefs about one's self Maladaptive patterns in family interactions Early lack of love and care
Exaggerated response to stressful life event
On admission to the psychiatric unit, a client is dressed in a red leotard and exercise bra, with an assortment of chains and brightly colored scarves on the client's head, waist, wrists, and ankles. The client's first words to the nurse are, "I'll punch you, munch you, crunch you," as the client dances into the room, shadow boxing. The client shakes the nurse's hand and says cheerfully, "We need to become better acquainted. I have the world's greatest intellect, and you are probably an intellectual midget." How can the nurse document the client's mood? Belligerent and blunted. Expansive and grandiose. Anxious and unpredictable. Suspicious and paranoid.
Expansive and grandiose.
A client has been diagnosed with depression and states that the client is reluctant to receive treatment, stating that the client "would prefer to just wait this out." What is the nurse's most appropriate action? Explain to the client that untreated depression often becomes increasingly severe and frequent over time Document a nursing diagnosis of ineffective denial and choose interventions accordingly Assess the client's knowledge of depression and describe the risks of suicide Document a nursing diagnosis of noncompliance and educate the client about the benefits of treatment
Explain to the client that untreated depression often becomes increasingly severe and frequent over time
A client with schizophrenia is receiving antipsychotic therapy. The nurse understands that which is a medical emergency should it develop in the client?
Neuroleptic malignant syndrome
Nursing Intervention: Stop all antipsychotic medications; notify physician immediately.
Neuroleptic malignant syndrome
A client with a diagnosis of schizophrenia has been brought to the emergency department by a worker from the group home where the client resides. The worker states that the client has stopped taking medications and drank 2 to 3 gallons of water over the past several hours. What assessments should the nurse who is caring for this client prioritize? Neurological assessment and monitoring of electrolyte levels Monitoring for evidence of hallucinations or delusions Blood glucose levels and body weight Assessing for allergic reactions, dry mouth, and lethargy
Neurological assessment and monitoring of electrolyte levels
A nurse is preparing an in-service program about schizophrenia for a group of psychiatric-mental health nurses. Which would the nurse include as a major reason for relapse?
Nonadherence to prescribed medications
Neurotransmitter that may be deficient in depression and increase in mania
Norepinephrine
Which biogenic amines have been implicated in depression? Norepinephrine and serotonin Epinephrine and dopamine Dopamine and histamine Epinephrine and serotonin
Norepinephrine and serotonin
Which is a true statement regarding depressive disorders? They are more prevalent in men than women. Depression in older adults is easier to diagnosis. Norepinephrine, dopamine, and serotonin have been implicated. It is the leading cause of U.S. disability in clients older than 44 years of age.
Norepinephrine, dopamine, and serotonin have been implicated.
A client with bipolar disorder is experiencing a major depressive episode. Which would the nurse expect to assess? Select all that apply. Flight of ideas Obsessive rumination Hypersomnia Widespread shopping sprees Difficulty concentrating
Obsessive rumination Hypersomnia Difficulty concentrating
A nurse is caring for a hospitalized client who has schizophrenia. The client has been taking antipsychotic medications for 1 week when the nurse observes that the client's eyes are fixed on the ceiling. The nurse interprets this finding as what?
Oculogyric crisis
A nurse provides care to a client with schizoaffective disorder during hospitalization for acute psychosis. Nursing interventions to help the client to establish trust with the health care team is best accomplished by what?
Offering reassurance in a soft, nonthreatening voice
Which should the nurse anticipate when providing therapy and evaluating outcomes for a client with delusional disorder? Easily attained Maintained for a short period only Achieved when delusions completely disappear within 6 months' time Often not met completely
Often not met completely
For which reason is depression in older adults often undiagnosed and untreated?
Older adult depression is often seen as "normal aging."
A client has been prescribed quetiapine for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which information?
One of the common side effects is dry mouth.
Which antidepressant medication is classified as a selective serotonin reuptake inhibitor (SSRI)?
Fluoxetine
Social withdrawal, few or no relationship, lack closeness
Asociality Negative
Inability to concentrate or focus on a topic or activity, regardless of its importance
Inattention Negative
Symptoms: muscle rigidity, high fever, increased muscle enzymes and leukocytosis-- serious and sometimes fatal
Neuroleptic Malignant Syndrome (NMS)
Which would a nurse expect to administer to a client with schizophrenia who is experiencing a dystonic reaction? Risperidone Aripiprazole Benztropine Trihexyphenidyl
Benztropine
The nurse has been asked to assess a client to determine if the client has a suicide plan. Which question would assist the nurse in assessing this area? "Are you a religious person?" "Do you have people in your life who are supportive of you?" "Are you thinking about killing yourself right now?" "How do you generally cope with problems in your life?"
"Are you thinking about killing yourself right now?"
The nurse is conducting an interview with an adult client who is being treated for major depression. What question should the nurse prioritize in an effort to determine the client's risk for suicide? "Do you ever feel like your situation is hopeless?" "How would you describe your relationship with your parents?" "Do you feel like your antidepressant is helping your mood?" "What are your plans for the next few days?"
"Do you ever feel like your situation is hopeless?"
When conducting a focused assessment on a newly admitted client who attempted suicide, which question should the nurse include to ensure the client's safety? Select all that apply. "Do you still have a plan to harm yourself?" "Have you ever tried to hurt yourself before?" "Are you willing to tell us if you plan to harm yourself again?" "Did you really want to kill yourself?" "Is there a history of depression in your family?"
"Do you still have a plan to harm yourself?" "Have you ever tried to hurt yourself before?" "Are you willing to tell us if you plan to harm yourself again?"
A nursing instructor is teaching about different depressive disorders and identifies a need for further instruction when a student states what? "Dysthymic disorder is milder than major depression." "Dysthymic disorder is less chronic than major depression." "With dysthymic disorder, depressed mood exists for most days for at least 2 years." "Dysthymic disorder can significantly affect a patient's functioning."
"Dysthymic disorder is less chronic than major depression."
A psychiatric nurse's colleague has expressed a reluctance to assess a client's risk for suicide, stating, "The last thing I want to do is to plant the thought in the client's head and bring on a suicide attempt." What is the nurse's best response? "Evidence shows that talking about suicide with clients doesn't cause suicide attempts." "We have an ethical responsibility to assess our clients for suicide risk, even if there are risks associated with doing so." "If a client is determined to make an attempt at suicide, there's nothing you or I can do to alter that." "Could it be that you're experiencing countertransference around your own fears of suicide?"
"Evidence shows that talking about suicide with clients doesn't cause suicide attempts."
The nurse is working with a client with schizophrenia who has cognitive deficits. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast? "I'll expect you in the dining room in 20 minutes." "First, wash your face and brush your teeth. Then put your clothes on." "Stay right there and I'll get your clothes." "Why don't you stay here and I'll get your tray for you."
"First, wash your face and brush your teeth. Then put your clothes on."
A 52-year-old client with bipolar disorder tells the nurse, "I read that there are chemicals in my brain that can cause my symptoms." Knowing that the client is referring to neurotransmitters, which would be the best response by the nurse? "Recent studies have found that neurotransmitters do not play a role in bipolar disorders." "Clients with bipolar disorder often have high levels of gamma-aminobutyric acid (GABA) in manic states." "High levels of the neurotransmitter serotonin are associated with mania." "Low levels of the neurotransmitter dopamine are associated with mania."
"High levels of the neurotransmitter serotonin are associated with mania."
The nurse is providing care for a client who deliberately overdosed on acetaminophen several days ago. The nurse should assess the current severity of the client's suicidal ideation by asking what question?
"How often are you having thoughts about suicide this morning?"
Which statement made by a client would indicate that the client has delusions of grandeur?
"I am a magician, and my magic powers are good when the moon is full."
A client in an inpatient setting has a delusion that there are a multitude of undetectable noxious gases in circulation that have the potential to poison the client and others. Which of the nurse's responses is most therapeutic? "There are actually no poison gases in the atmosphere that we don't know about." "Why do you think that you keep insisting on this belief?" "I can assure you that you are actually very safe here." "If we detect a poison gas here, I promise that you'll be the first to know."
"I can assure you that you are actually very safe here."
The psychiatric nurse documents that a client is expressing nihilistic delusions when the client makes which statement? "I can't eat; I have no mouth or stomach." "I'm dying; I'm the first to have this form of cancer." "I'll just telephone the president; he always answers my calls." "I need to leave now; I'm expecting a visit from my sister, the queen.
"I can't eat; I have no mouth or stomach."
A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which is the most therapeutic response by the nurse? "I don't hear the voice, but I know you hear what sounds like a voice." "You shouldn't focus on Elvis's voice." "Don't worry about the voice as long as it doesn't belong to anyone real." "You know that Elvis has been dead for years."
"I don't hear the voice, but I know you hear what sounds like a voice."
During a night shift, a hospitalized client with depression tells a nurse that the client is going to kill himself or herself. The client is placed on constant observation. When the client asks to use the toilet, the nurse follows the client into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which response by the nurse is most appropriate? "You're right. I don't need to come into the bathroom with you. I will wait outside the door." "I must stay with you until we are sure you will not hurt yourself." "If you think you are going to be OK, I will check on you in 5 minutes." "I can't imagine anything dangerous is in the bathroom. Go ahead. I will wait for you in the hallway."
"I must stay with you until we are sure you will not hurt yourself."
After teaching a client with schizoaffective disorder about the condition and treatment, the nurse determines that the education was successful when the client states what?
"I need to eat properly so that I can control my weight."
A client has been recently diagnosed with depression and has just started taking an antidepressant medication. Which of the client's statements indicates an accurate understanding of this aspect of treatment? "I'm still trying to decide whether antidepressants will be helpful in my treatment." "I understand that I probably won't feel much better for a couple of weeks after I start the drugs." "I can tell that I get a lift each morning after I take my antidepressant." "I know that few people actually see an improvement in their mood with antidepressants, but I suppose I'll try anyhow."
"I understand that I probably won't feel much better for a couple of weeks after I start the drugs."
The nurse is interviewing a client with a diagnosis of depression and the client states, "Honestly, I know my family would be a lot better off if I wasn't around to be a burden on them. That's just between you and me, though, okay?" What is the nurse's best response? "I'm obliged to share what we talk about with the other people on your care team." "Why is it important to you that this be kept between you and I?" "In my experience, nothing good ever comes of keeping secrets." "What can I do to get your permission to share with the other members of the care team?"
"I'm obliged to share what we talk about with the other people on your care team."
A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being "down." When assessing the client, which statement by the client would alert the nurse to suspect possible suicide? Select all that apply.
"I've been drinking about three or four more beers every night." "I'm so tired that all I ever want to do is sleep all the time." "Most times, I feel like I'm trapped with no way out."
In working with the individual and family, which is the most accurate statement the nurse can make in order to teach the client and family about schizophrenia?
"Individuals with schizophrenia do have differences in brain structure and function that cause a variety of symptoms such as lack of motivation and hearing voices."
The nurse working with a client who is newly diagnosed with schizophrenia would include which in the client's education? "Schizophrenia is an illness that involves neurotransmitters, more specifically dopamine." "Schizophrenia is caused by pathology in the cerebellum, and there are medications that are helpful in this area." "Schizophrenia has been found to be nonresponsive to medications, and we will work mostly on helping you with daily activities." "Schizophrenia is curable if the correct medication and dosages are achieved."
"Schizophrenia is an illness that involves neurotransmitters, more specifically dopamine."
A client is to receive three treatments of electroconvulsive therapy (ECT) per week for 3 weeks. After the third treatment, the client is forgetful and confused. When the client's spouse arrives to take the client home, the nurse discusses the client's condition with the spouse. Which statement is best? "Some confusion after ECT is normal. The client will regain memory in a few hours." "Confusion after ECT is not expected. Though it will resolve, the client probably will not be a candidate for ECT in the future." "Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer." "Some confusion after ECT is normal. Withhold the client's medications for today and call tomorrow to let us know how the client is doing."
"Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer."
A psychiatric-mental health nurse is conducting an in-service education program about suicide for a group of nurses working at a community mental health center. The nurse determines that the teaching was successful based on which statement by the group? "Suicide is more of a concern in countries other than the United States." "Suicide does not occur in affluent neighborhoods, indicating poverty is a factor." "Suicide has profound effects on those connected to the individual." "Suicide rates among older adults are low."
"Suicide has profound effects on those connected to the individual."
A client with a diagnosis of depression tells the nurse that the client's mood was especially bad this morning but that the client pushed through it to attend a support group. How can the nurse best validate the client?
"That shows an admirable level of perseverance on your part. Well done!"
A client in the psychiatric unit of the hospital has a diagnosis of schizophrenia. The client has approached the nurse in the hallway of the hospital and is elaborating in great detail about the client's delusions of persecution involving secret societies, the Vatican, and the mafia. How should the nurse respond to the client's expression of these delusions? "Do you think that your delusions might be causing you to think this way?" "That sounds very stressful for you. Would you like to join me and the others in the lounge?" "What can I do to help you get away from these people who want to get you?" "Remember that none of this is real and that no one at all is trying to harm you."
"That sounds very stressful for you. Would you like to join me and the others in the lounge?"
The spouse of a client diagnosed recently with a mood disorder calls the nurse therapist to report a change in the client's mood. The spouse states, "The client is clearly in a better mood than usual. I would say the client seems mildly elated. The client is functioning fine at work and home. The client is energetic, up and doing things at 5:00 a.m. and really confident again. It seems fantastic, but unusual. Is this something to worry about?" Which potential response by the nurse accurately assesses the situation? "It sounds as though the antidepressants are working well. Just ask the client if the client is experiencing any side effects and let me know." "I'm concerned. Sometimes depressed people seem contented when they have decided to commit suicide. Let's schedule an appointment for tomorrow." "Since the client is eating, sleeping, and not behaving inappropriately, there's nothing to worry about. Just let me know if the client starts getting irritable or has trouble sleeping." "The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication."
"The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication."
A nurse is completing an admission assessment of a young male client who has a history of depression and who was brought to the hospital by the client's partner. In response to the nurse's question regarding suicidal ideation, the client discloses that he is thinking about killing himself. Which question would be most appropriate for the nurse to ask next? "What does your partner think about your desire to kill yourself?" "What are your spiritual beliefs about suicide?" "What will killing yourself accomplish?" "What thoughts have you had about how you would kill yourself?"
"What thoughts have you had about how you would kill yourself?"
The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response?
"The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."
A client whose mania is related to a medical condition asks why the physician has prescribed carbamazepine instead of lithium. Which is the nurse's best response? "This drug may be preferred by your physician for many reasons." "This drug is best for clients who do not respond to lithium or whose mania is related to a medical condition, as is yours." "You will be fine taking this drug, so don't worry." "I don't know. Make sure you discuss this with your doctor as soon as you can."
"This drug is best for clients who do not respond to lithium or whose mania is related to a medical condition, as is yours."
A client with schizophrenia is prescribed clozapine because other prescribed medications have been ineffective. After educating the client and family about the drug, the nurse determines that the education was successful when they state: "The client needs to have an electrocardiogram periodically when taking this drug." "We'll need to make sure that the client has the client's blood count checked at least weekly." "The client might develop toxic levels of the drug if the client smokes cigarettes." "We need to watch to make sure that the client doesn't lose too much weight."
"We'll need to make sure that the client has the client's blood count checked at least weekly."
A client comes to the emergency department reporting a severe pounding headache in the temples and a stiff neck. The client is flushed and diaphoretic, and the client's pulse is racing. The client states that the client is being treated for depression with an MAOI. Which question by the nurse would be most important to ask at this time? "When did you last have blood drawn to check your drug level?" "What have you had to eat or drink today?" "Are you having any chest pain?" "Do you use any herbal remedies?"
"What have you had to eat or drink today?"
A client who is delusional and paranoid refuses to take antipsychotic medication as prescribed. Which is the most therapeutic response by the nurse to this refusal?
"What is it about the medicine that you don't like?"
Increase fluid and fiber intake to avoid constipation; use ice chips or hard candy for dry mouth; assess for memory impairment (another side effect).
Benztropine (Cogentin)
A client with a persecutory delusion has been explaining to the nurse the specifics of the conspiracy against the client. The client pauses and says, "I get the feeling that you don't actually believe that what I'm telling you is true." How should the nurse respond? "What you're telling me is difficult for me to believe. This may be real for you, but not me." "What's important to me is that it's real for you." "The conspiracy that you're explaining to me is actually a delusion." "What makes you think that I don't believe you?"
"What you're telling me is difficult for me to believe. This may be real for you, but not me."
A client has just been diagnosed with bipolar disorder and is upset with the diagnosis. The client tells the nurse, "It is probably my mother's fault, she has bipolar too." Which is the best response by the nurse? "Bipolar disorders have not been found to be genetic." "While bipolar disorders are genetic, there are other causes as well." "While bipolar disorders are genetic, the gene can only be passed on by a father." "Genetics are a minor factor in bipolar; it is more heavily influenced by psychological factors."
"While bipolar disorders are genetic, there are other causes as well."
A 38-year-old client has been diagnosed with major depressive disorder. The client is being placed on an antidepressant and the nurse is providing medication teaching. Which would be appropriate information to provide to the client?
"You may not notice an improvement in your symptoms for 2 to 6 weeks."
A client has experienced a first episode of major depression and has received medication and treatment, which has led to a complete remission of the symptoms. The client asks the nurse, "How much longer will I need to take the medication?" Which response by the nurse would be most appropriate? "You'll need to continue the medication for about 6 to 12 months to see how things go." "It's probably best to continue the medication for another month, gradually decreasing the dosage over that time." "Since you have no more symptoms, you can stop taking the medications tomorrow." "The medication has eliminated your symptoms so you'll need to keep taking it for the rest of your life."
"You'll need to continue the medication for about 6 to 12 months to see how things go."
Which client statement is suggestive of a sexual delusion?
"You've been watching me and my partner while we are together, haven't you?"
A client is diagnosed with schizophreniform disorder. The nurse is reviewing the client's medical record and finds that the client's symptoms have been present for at least how long? 1 week 1 month 8 months 1 year
1 month
A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what?
1.0 mEq/L
Research has shown that risk of suicide increases within which time frame for initiation of antidepressant therapy?
14 days
Which medication classification has been most effective in treating akathisia? Beta-blockers Antimanics Antianxiety Sedatives
Beta-blockers
The mental health nurse appropriately provides education on light therapy to which client? 20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term 58-year-old showing signs of early Alzheimer's disease 45-year-old lawyer whose medication therapy needs an additional treatment 50-year-old farmer whose major depression has not responded to any treatment modality
20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term
A client diagnosed with schizophreniform disorder must have symptoms present for at least 1 month but with a duration of less than how long?
6 months
When completing discharge medication education for the client, the client asks how long it will take before the selective serotonin reuptake inhibitor (SSRI) medication will help the client's mood improve. Which is the correct response by the nurse? 1 to 2 days 5 to 7 days 7 to 10 days 3 to 4 weeks
7 to 10 days
Which client exhibits the characteristics that are typical of the prodromal phase of schizophrenia?
A 20-year-old is experiencing a gradual decrease in the ability to concentrate, be productive, and sleep restfully.
Which individual has the highest number of risk factors for the development of depression? A 42-year-old woman who has experienced depression before but has a strong support system A 32-year-old man who has been diagnosed with cancer and has been abusing alcohol A 50-year-old woman who just lost her spouse and has a family history of depression A 62-year-old man who has had depression in the past and abuses alcohol
A 50-year-old woman who just lost her spouse and has a family history of depression
The nurse expects psychiatric hospitalization for which of the clients diagnosed with schizoaffective disorder experiencing delusional thoughts? Select all that apply. A 76-year-old person whose symptoms are acute in nature A 25-year-old person who is having a first delusional experience A 45-year-old person who was arrested for assaulting a policeman A 30-year-old person who also has a diagnosis of depression A 39-year-old person who reports minor side effects from the current medication
A 76-year-old person whose symptoms are acute in nature A 25-year-old person who is having a first delusional experience A 45-year-old person who was arrested for assaulting a policeman A 30-year-old person who also has a diagnosis of depression
Which sleep pattern is suggestive of a manic episode? A client stays awake for several days and nights before "crashing" and sleeping for a long period. A client experiences day-night reversal, sleeping until late in the afternoon and going to bed near dawn. A client reports having fitful sleep that is characterized by frequent awakenings and nightmares. A client takes multiple short naps at varied times throughout the day and night.
A client stays awake for several days and nights before "crashing" and sleeping for a long period.
Which client is most likely to benefit from electroconvulsive therapy (ECT)?
A client whose major depression has not responded appreciably to antidepressants
A 46-year-old client has been diagnosed with major depressive disorder. The client is seeing a nurse practitioner who is deciding on an appropriate treatment regimen. The nurse practitioner knows that which will be the most effective treatment for this client's depressive disorder?
A combination of psychotherapy and medication
A nurse teaching a client about prescribed antipsychotic medication informs the client to contact a health care provider immediately if the client notices: An increase in weight of 2 lbs in 1 month. A feeling of dizziness when the client stands up. An increase in thirst. A dramatic change in temperature.
A dramatic change in temperature.
A 46-year-old client comes to the community mental health center because the client thinks they might be suffering from depression. When assessing this client, which symptom would the nurse identify as being necessary for the diagnosis of major depressive disorder to be made? Euphoria along with poor decision making ability Disregard for personal hygiene including cleanliness and appearance A loss of interest or inability to derive pleasure for previously enjoyed activities A stooped posture and nonverbal signs of a depressed mood
A loss of interest or inability to derive pleasure for previously enjoyed activities
A client was abandoned by the parents at age 3, resulting in the client's perception of the world as a hostile place and the subsequent development of rage against men. This statement is an example of what?
A psychodynamic interpretation of the client's major depressive disorder.
A client has been diagnosed with major depressive disorder. The clinical symptom that would be included when the clinician makes this diagnosis is what?
A significant decrease in appetite
The clinical symptom that would be included when the clinician makes this diagnosis is what? Self-report of being sad after a break up A significant decrease in appetite Demonstrated examples of unwise decisions Claims by family, friends, or coworkers that the client is depressed
A significant decrease in appetite
The community mental health nurse is providing care for a large number of clients. What client should the nurse monitor most closely for the warning signs of suicide? A young male with schizophrenia who is in danger of becoming homeless An adult female who is mourning the death of her husband 5 months ago An older adult client who has recently been diagnosed with early stage Alzheimer disease A middle-aged female client who is receiving treatment for obsessive-compulsive disorder
A young male with schizophrenia who is in danger of becoming homeless
Which group of theories is believed currently to explain the etiology of schizophrenia? Behavioral Cognitive Family system Biologic
Biologic
Holding seemingly contradictory believes of feelings about the same person, event or situation
Ambivalence Postive
A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client? Ability to concentrate and process the information Likelihood to assume responsibility for self-care Cognitive awareness and intellectual abilities Interest in learning about the disorder
Ability to concentrate and process the information
The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority?
Administering a mental status exam to assess for psychosis
A client has just been diagnosed with a major depressive disorder following recent problems with the client's mood, work performance, and sleep quality. When planning this client's care, the nurse should anticipate what interventions? Select all that apply. Administration of a sustained serotonin reuptake inhibitor (SSRI) Administration of an monoamine oxidase inhibitor (MAOI) Phototherapy Cognitive therapy Repetitive transcranial magnetic stimulation (rTMS)
Administration of a sustained serotonin reuptake inhibitor (SSRI) Cognitive therapy
Pervasive alterations in emotions that are manifested by depression, mania, or both
Affective disorder
Which must be present in a client diagnosed with serotonin syndrome? Select all that apply. Agitation Hyporeflexia Diaphoresis Constipation Ataxia Fever
Agitation Diaphoresis Ataxia Fever
A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effect of this medication?
Agranulocytosis
A mental health client has been prescribed clozapine for the treatment of schizophrenia. The nurse should be alert to which potentially life-threatening adverse effects of this medication?
Agranulocytosis
Characterized by restless movement, pacing, inability to remain still and client report of inner restlessness
Akathisia
Nursing Intervention: Administer medications as ordered; assess for effectiveness.
Akathisia
A nurse monitoring client medication needs to recognize side effects quickly and intervene promptly for which reason? Determine adequate dosage is maintained to control symptoms Alleviate the side effects and help client maintain adherence Provide support to the client and let the client know this is normal Provide support to the client and encourage adherence as past side effects rarely reoccur
Alleviate the side effects and help client maintain adherence
Tendency to speak very little or to convey little substance of meaning
Alogia Negative
A 51-year-old client has been severely depressed and has been contemplating suicide. While feeling like the client has no other way out, the client also wishes someone would help. What is this is known as? Ambivalence Rescue syndrome Determination Vacillation
Ambivalence
Which characteristic is most common among suicidal clients? Ambivalence Psychosis Remorse Anger
Ambivalence
The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what?
An elevated mood that lasts for at least 1 week
Lack of energy
Anergia
The nurse is seeing a 43-year-old client whose spouse just died by suicide. Which is a common emotional response that the nurse should anticipate from this client? Anger toward the loved one who committed suicide The development of a panic disorder Turning toward alcohol or drugs Unpredictable behavior and a potential for risk-taking behaviors
Anger toward the loved one who committed suicide
A loss of pleasure or interest in a client diagnosed with depression would be documented as what?
Anhedonia
Feeling no joy or pleasure from life or any activities or relationship
Anhedonia Negative
A 34-year-old client with depression is admitted to an inpatient psychiatric unit. The nurse enters the client's room and initiates interaction with the client. When talking with the client, which approach would be least appropriate?
Animated and cheerful manner
Feelings of indifference toward people, activity, and events
Apathy Negative
A client is admitted to the psychiatric unit after taking various medications and illegal substances to get "high." In addition to the underlying diagnosis of bipolar disorder, the client is diagnosed with delirium. Currently the client is experiencing mild hallucinations and confusion. Which intervention should the nurse do first? Loosely apply a vest restraint. Obtain an order for haloperidol. Arrange for an unlicensed assistant to sit with the client. Ask a family member to stay with the client and report any concerns.
Arrange for an unlicensed assistant to sit with the client.
A client with schizophrenia walks up to the nurse with the client's arm outstretched and says, "My arm went away. Dog, dog, dog." How should the nurse respond? Ignore the comments and redirect the client's attention. Ask the client if the client is trying to say that something is wrong with the client's arm. Ask the client if the client is having visual hallucinations. Tell the client that he or she can see the arm, and no dogs are around.
Ask the client if the client is trying to say that something is wrong with the client's arm.
A client with schizophrenia, who has a history of repeated hospitalizations and homelessness, is ready for discharge. The nurse is developing a plan for the client's continued care in the community. Which discharge intervention will most likely prevent relapse for this client? Assertive community treatment Monthly follow-up in the community mental health clinic Referral to a vocational counselor Family education about relapse prevention
Assertive community treatment
A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action?
Assess the client's blood pressure
The policies and procedures at a community psychiatric-mental health center include an emphasis on case finding. How can a nurse at the center best perform case finding?
Assessing all clients carefully to identify those at risk for suicide
A 20-year-old client was admitted to the inpatient unit following a suicide attempt. The client is disheveled, disorganized, and dehydrated. The priority for the client's care during the first 24 hours of admission will be what? --Assisting the client with activities of daily living, including a shower and clean clothing. --Assessing the client's current suicidal ideation and putting the client on suicide precautions. --Rehydrating the client by forcing fluids. -- Assessing the client's recent suicide attempt and identifying factors that may have contributed to it.
Assessing the client's current suicidal ideation and putting the client on suicide precautions.
Fragmented or poorly related thoughts and ideas
Associative looseness Postive
A client with schizoaffective disorder is prescribed long-term medication therapy. The nurse would most likely expect what to be prescribed as the mainstay of treatment? Atypical antipsychotic Mood stabilizer Antidepressant Typical antipsychotic
Atypical antipsychotic
Absence of will, ambition, or drive to take action or accomplish task
Avolition Negative
Which is a food that might be incorporated into the plan of care for a client diagnosed in the manic phase of bipolar disorder? Bananas Brocolli Spaghetti Steak
Bananas
A client has been diagnosed with schizophrenia. Assessment reveals that the client lives alone. The client's clothing is disheveled, the client's hair is uncombed and matted, and the client's body has a strange odor. During an interview, the client's family members voice a desire for the client to live with them when the client is discharged. Based on the assessment findings, which nursing diagnosis would be the priority? Ineffective role performance related to symptoms of schizophrenia Social isolation related to auditory hallucinations Dysfunctional family processes related to psychosis Bathing self-care deficit related to symptoms of schizophrenia
Bathing self-care deficit related to symptoms of schizophrenia
Which statement is true about delusional disorder? The disease onset is usually gradual. Psychosocial functioning is often markedly impaired. Behavior is relatively normal except when focused on the delusion. The individual's personality changes dramatically.
Behavior is relatively normal except when focused on the delusion.
Which type of therapy involves increasing the frequency of the client's positively reinforcing interactions with the environment and to decrease negative interactions?
Behavior therapy
The experienced psychiatric nurse shares with the novice nurse that effective nursing care for the delusional client depends on what? Select all that apply. Being relaxed during frequent client-nurse interactions Expecting the client to adhere to all unit rules Managing the milieu so as to minimize situations that will frustrate or anger the client Remaining in confrontation with the client until the delusions are neutralized Supporting the delusion only when the client is extremely agitated
Being relaxed during frequent client-nurse interactions Expecting the client to adhere to all unit rules Managing the milieu so as to minimize situations that will frustrate or anger the client
Which medication is used to control the extrapyramidal effects associated with antipsychotic medications? Benzotropine Chlorpromazine Haloperidol Thioridazine
Benzotropine
A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile? Bipolar II Cyclothymic disorder Bipolar I Euthymic state
Bipolar I
One or more manic or mixed episode usually accompanied by major depressive episodes (Mania, Hypomania (cyclothymia), major depression)
Bipolar I
A nursing instructor is teaching about mood disorders and informs the class that bipolar disorder is divided into several groups. Those groups include what? Select all that apply. Bipolar I Bipolar II Bipolar III Bipolar mixed Bipolar IV
Bipolar I Bipolar II Bipolar mixed
When teaching a client who is recently diagnosed bipolar I disorder, the nurse correctly tells the client that the difference between bipolar I disorder and bipolar II disorder is what? Bipolar I disorder is often more disruptive than bipolar II disorder. Bipolar I disorder more often effects women. Bipolar I disorder is characterized by hypomanic episodes. Bipolar I disorder involves altered moods of anger and paranoia.
Bipolar I disorder is often more disruptive than bipolar II disorder.
One or more major depressive episodes accompanied by at least one hypomanic episode (Hypomania, minor depression, major depression)
Bipolar II
Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior
Bizarre Behavior Positive
Restricted range of emotional feeling, tone or mood
Blunted Affect Negative
A client was admitted to the psychiatric intensive care unit with schizophrenia. The client exhibits primarily disorganized behavior. In addition to hallucinations and delusions, other assessments that the nurse would expect to find include what? Blunted inappropriate affect, withdrawal, incoherence, and confusion Abnormal, bizarre posturing; stupor; echolalia; and negativism Hostility, aggression, persecutory hallucinations, and argumentativeness Depression, elation, hyperactivity, and pressure of speech
Blunted inappropriate affect, withdrawal, incoherence, and confusion
A nurse is preparing to document information obtained from a client diagnosed with a s disorder who is experiencing somatic delusions. Which would the nurse most likely document? Disorientation Reduced attention span Above average intelligence Body complaints
Body complaints
A 42-year-old client with major depression is in an inpatient psychiatric hospital. The client has been taking phenelzine, a monoamine oxidase inhibitor (MAOI), for depression. The therapist writes an order to discontinue the phenelzine and begin fluoxetine. Which action by the nurse is indicated? Begin educating the client about food restrictions when taking fluoxetine. Begin educating the client about selective serotonin reuptake inhibitors. Call the therapist to discuss the need for a washout period before starting fluoxetine. Note in the medication administration record to check the client's blood pressure for the first 2 days after starting fluoxetine.
Call the therapist to discuss the need for a washout period before starting fluoxetine.
A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications? Mannitol Lithium Carbamazepine Methyldopa
Carbamazepine
A client with a persistent delusional disorder has been prescribed ziprasidone. Which assessment should the nurse prioritize when this medication regimen begins? Cardiac and neurological assessments Respiratory assessment including oxygen saturation Monitoring of fluid and electrolyte levels Integumentary and gastrointestinal assessments
Cardiac and neurological assessments
A psychiatric-mental health nurse is conducting a refresher class for a group of psychiatric-mental health nurses returning to the field. After teaching about depressive disorders, the nurse determines a need for additional teachig when the class identifies which physical symptom as being associated with depression? Catatonia Fatigue Insomnia Worthlessness
Catatonia
Psychologically induced immobility occasionally marked by periods of agitation and excitement, the client seems motionless, as if in a trance
Catatonia Negative
The nurse notes that a client with schizophrenia sits in a chair rocking back and forth. What does the nurse recognizes this as? A side effect of medication Catatonic stupor Catatonic excitement A sign of anxiety
Catatonic excitement
The nurse educates a class on factors that enhance the risk of suicide. The instructor determines the need for additional education when the class identifies which as one of these factors?
Cautiousness
A client with schizoaffective disorder is engaging in an extremely long conversation about a current affairs in the world. The client goes on to provide the nurse with minute details. The nurse interprets this as suggesting what? Circumstantiality Neologism Verbigeration Clang association
Circumstantiality
Which speech pattern is exhibited by the client stating, "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill?" Clang association Neologism Verbigeration Word salad
Clang association
A client who suffers from bipolar disorder is admitted to a mental health unit for a manic episode. The nurse knows that which takes priority? Phamacotherapy Client safety Cognitive-behavioral therapy Distraction therapy
Client safety
A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified? Client will express that the client feels safe on the unit Client will implement strategies for managing stress Client will participate actively in cognitive behavioral therapy Client will state that the client feels optimistic about the client's future
Client will express that the client feels safe on the unit
A psychiatric-mental health nurse is conducting a review class for a group of colleagues about schizoaffective disorder. The nurse determines that the class was successful based on which description of the condition by the group? Delusions are present but hallucinations are absent. Clients are often misdiagnosed as having schizophrenia. The symptoms typically run a fairly constant course. Mood symptoms must occur consistently with positive symptoms.
Clients are often misdiagnosed as having schizophrenia.
The major difference between bipolar I and bipolar II disorder is what?
Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances.
The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client? Lithium Haloperidol Chlorpromazine Clozapine
Clozapine
The severity of a client's positive and negative symptoms of schizophrenia has not significantly improved since treatment began, despite the use of three different neuroleptic medications. The nurse should anticipate that this client may benefit from treatment with which medication? Clozapine Haloperidol Risperidone Olanzapine
Clozapine
An adult client was admitted to the psychiatric mental health unit following a suicide attempt. The client has responded well to treatment, so discharge is being considered. In anticipation of the client's discharge, the nurse should:
Collaborate with the family to make sure the client's home environment is safe.
When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what?
Communicate concern and empathy to the client
When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what in a client?
Confusion
A nurse suspects that a client has overdosed on the prescribed tricyclic antidepressant. Which assessment finding would support this suspicion? Select all that apply. Confusion Hallucinations Agitation Orthostatic hypotension Headache
Confusion Hallucinations Agitation
Which are key diagnostic criteria of schizophrenia? Select all that apply. Continuous signs for at least 6 months One or more major areas of social or occupational functioning markedly below previously achieved levels Delusions present for a significant portion of time during a 1-month period A direct physiologic effect of a substance or medical condition Major depression occurring concurrently with active symptoms
Continuous signs for at least 6 months One or more major areas of social or occupational functioning markedly below previously achieved levels Delusions present for a significant portion of time during a 1-month period
An elderly client is admitted to the hospital with fatigue and weight loss of 20 pounds in 1 month. Upon further assessment, the client is diagnosed with depression. What other thing should the nurse assess this client for based on the weight loss?
Dehydration
Mild mood swings between hypomania and depression without loss of social or occupational functioning
Cyclothymic Disorder
Fixed false belief that have no basis in reality
Delusion Postive
A client with schizophrenia states that the client is God's messenger and the client's mission is to become president. The nurse documents these comments as evidence of what? Delusional thinking Hallucinatory experiences Bizarre behavior Formal thought disorder
Delusional thinking
A nurse is assessing a client diagnosed with schizophrenia. When documenting the findings, which would the nurse identify as a positive symptom? Select all that apply. Delusions Hallucinations Alogia Anhedonia Avolition
Delusions Hallucinations
A nurse is assessing a client diagnosed with delusional disorder. The nurse would expect to find what? Delusions with a prominent theme Prominent hallucinations Prolonged mood episodes Underlying substance use
Delusions with a prominent theme
Which mental health disorder has the most significant risk factor for suicide?
Depression
A nurse is preparing a presentation for family members of clients who have been diagnosed with depression. When describing the family response to depression, which would the nurse include? Family members typically can understand how disabling depression can be. Depression in one family member affects the entire family. Abuse of the depressed person is a rare occurrence in families. Families of women older than 55 years of age with depression experience the majority of problems.
Depression in one family member affects the entire family.
After teaching a group of nursing students about major depression, the instructor determines that the education was successful when the group identifies which information is accurate? Onset of depression is common in adolescence Depression is twice as common in women than in men Depression is correlated with low intellectual ability Onset of depression is most common in middle-aged persons
Depression is twice as common in women than in men
A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. The client's suicidal risk has lessened considerably, and the client currently denies having any desire to kill himself or herself. In addition, the client is able to identify reasons why the client wants to be alive. Which nursing intervention would be most appropriate at this time? Assigning nursing staff to stay with the client during the suicidal crisis Developing a personal plan for managing suicidal thoughts when they occur Advising the client to consider electroconvulsive therapy treatments Administering psychotropic drugs that decrease the client's serotonin levels
Developing a personal plan for managing suicidal thoughts when they occur
A client on the psychiatric mental health unit completed suicide. A nurse who cared for the client has been experiencing insomnia and anxiety attacks since the event. What is the nurse's first action?
Dialogue with a trusted colleague about these feelings
A hospitalized client with schizophrenia is receiving antipsychotic medications. While assessing the client, a nurse identifies signs and symptoms of a dystonic reaction. Which agent would the nurse expect to administer? Diphenhydramine Propranolol Risperidone Aripiprazole
Diphenhydramine
Use ice chips or hard candy for dry mouth; observe for sedation.
Diphenhydramine (Benadryl)
The relationships and associations among the words used to express thoughts are markedly disturbed in clients with schizophrenia. What is this disturbance characterized by? Disorganized speech Auditory hallucinations Flight of ideas Paucity of speech
Disorganized speech
Before a client became depressed, the client was an active, involved parent with three children, often attending school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals feeling like an unnecessary burden on the family. Which nursing diagnosis is most appropriate?
Disturbance of self-concept related to feelings of worthlessness
Continuous flow of verbalization in which the person jumps rapidly from one topic to another
Flight of ideas Positive
The nurse is developing a care plan for a client with somatic delusions. Which would be an appropriate nursing diagnosis for this client? Disturbed sleep pattern Risk for self-directed violence Chronic low self-esteem Disturbed thought process
Disturbed thought process
Which is an anticonvulsant used as a mood stabilizer?
Divalproex
A client with schizophrenia is exhibiting hallucinations and delusions. The mental health nurse knows that these symptoms are associated with hyperactivity of which neurotransmitter?
Dopamine
A group of nursing students is reviewing the various theories related to the etiology of schizophrenia. The students demonstrate understanding of the information when they identify which neurotransmitter as being responsible for hallucinations and delusions? Dopamine Serotonin Norepinephrine Gamma-aminobutyric acid (GABA)
Dopamine
Chronic persistent mood disturbances characterized by symptoms including insomnia, loss of appetite, decreased energy, difficulty concentrating, feelings of sadness
Dysthymic Disorder
A nurse is giving a presentation on mental health promotion at a community center. A participant states, "My friend tells me I'm depressed because I don't have a lot of energy and have trouble concentrating. I had to quit my full-time job because I don't seem to have the energy to manage it. But I don't want to kill myself or anything like that." Although more data are needed for diagnosis, the nurse suspects that the client may have what? Bipolar II disorder Cyclothymic disorder Dysthymic disorder Major depressive disorder
Dysthymic disorder
Appear early in course of treatment, spasms in discrete muscle groups (ex: neck or eye muscles)
Dystonic reactions
Nursing Intervention: Administer medications as ordered; assess for effectiveness; reassure client if he or she is frightened.
Dystonic reactions
What term is used to describe the speech pattern being used when the client imitates or repeats what the nurse is saying?
Echolalia
Imitation of the movements and gestures of another person whom the client is observing
Echopraxia Postive
A client with a diagnosis of bipolar disorder is described by a family member as "flip-flopping between being happy and loving to irritable and hostile." Which characteristic symptoms of this disorder is the family member referring to? Euthymic mood Emotional lability Manic episode Grandiosity
Emotional lability
When preparing to educate a client regarding a newly prescribed antipsychotic medication, which action would be most appropriate for the nurse to do? Select all that apply. Encourage the use of sugar-free gum to help manage dry mouth Suggest methods to minimize the potential for weight gain Identify lifestyle adjustments that the resulting lethargy may require Advise the client to discuss any concerns regarding sexual dysfunction Discuss the increased difficulty the medication has on conception for both genders
Encourage the use of sugar-free gum to help manage dry mouth Suggest methods to minimize the potential for weight gain Identify lifestyle adjustments that the resulting lethargy may require Advise the client to discuss any concerns regarding sexual dysfunction
The nurse is performing the initial assessment of a client diagnosed with schizophrenia. What should be the nurse's approach while assessing this client? Select all that apply. Engage in a one-to-one interaction with the client Provide effective physical care Perform diagnostic testing Expect the client will have cognitive deficits Establish a therapeutic relationship
Engage in a one-to-one interaction with the client Establish a therapeutic relationship
A client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action? Ensuring a plan is in place for the client's community-based care Ensuring that the client has created a commitment to treatment statement Documenting the client's psychiatric advance directive Communicating with the pharmacy where the client will obtain prescribed medications
Ensuring a plan is in place for the client's community-based care
After educating a class on the etiology of bipolar disorders, a nursing instructor determines that the education was successful when the class describes the kindling theory as involving what? A dysregulation in the circadian rhythm, leading to sleep disturbance A single gene or sequence of genes causing pathologic changes Exposure to repetitive subthreshold stressors at vulnerable times "Wear and tear" on the body from mood episodes leading to increased problems
Exposure to repetitive subthreshold stressors at vulnerable times
A client has been taking haloperidol for 5 years when the client is admitted to the inpatient unit for relapse of symptoms of schizophrenia. Upon assessment, the client demonstrates akathisia, dystonia, a stiff gait, and rigid posture. The nurse correctly identifies these symptoms are indicative of what? Psychosis Tardive dyskinesia Extrapyramidal side effects Progressed schizophrenia
Extrapyramidal side effects
Reversible movement disorders induced by neuroleptic meds
Extrapyramidal side effects
Which statement regarding gender and suicide is correct?
Females engage in suicidal behaviors more frequently than males.
The nurse knows that the most dangerous time period following a previous suicide attempt is what? First 3 months First 6 months First 9 months First year
First 3 months
Following a change in job position, a minister asks a client how the client likes the new job. The client states, "Oh everything is great. I can really see myself going far in this new position." However, the client's voice is monotone and the client's face is nearly absent of affective expression. The minister is worried about this client and describes this facial expression as what?
Flat
Absence of any facial expression that would indicate emotions or mood
Flat Affect Negative
Racing, often unconnected thoughts; excessive amount and rate of speech comprised of fragmented or unrelated ideas
Flight of Ideas
A nurse is preparing to administer prescribed antipsychotic medication to a client with psychosis. The nurse identifies the prescribed medication as a first-generation antipsychotic drug. Which drug would the nurse most likely be administering? Fluphenazine Aripiprazole Clozapine Olanzapine
Fluphenazine
A married couple arrives at the outpatient clinic. Upon assessment, the nurse finds that the couple believes that the police have been following them and tapping their phones for 2 months. This couple most likely suffers from which disorder? Folie à deux Psychotic disorder, not otherwise specified Delusional disorder, paranoid type Conjugal delusion
Folie à deux
A client has been on lithium for 3 weeks now. The client approaches the nurse, saying, "I feel like I'm going to throw up, and I can't even hold this cup of coffee straight. Why can't I do the crossword puzzle? I usually can do them in about 5 minutes." What is the appropriate nursing intervention at this time?
Further assess the client's symptoms, call the physician, hold the client's next dose of lithium, and have a blood level drawn because the client is showing symptoms of toxicity.
A 32-year-old client is admitted to the inpatient unit for depression with suicidal thoughts. During the nursing assessment, why it is important for the nurse to assess and explore if there is any family member who has committed suicide? Genetic predisposition Disengagement of family Lack of conflict resolution skills Terminal illness
Genetic predisposition
When teaching prevention to the parents of a 15-year-old client who recently attempted suicide by taking an overdose of alprazolam, the nurse describes which behavioral clue? Angry outbursts at significant others Inquiry about doses of lethal drugs Giving away valued personal items Experiencing the loss of a boyfriend or girlfriend
Giving away valued personal items
A client diagnosed with schizophrenia is telling everyone that the client is the president of the United States. This client is exhibiting which type of delusion?
Grandiose
During a client interview, a client states that "God has sent me a special message. I'm the only one who can carry out his plan." The nurse interprets this statement as suggesting which type of delusion?
Grandiose
A client with schizophrenia believes that the client has discovered how to jump to the moon. The nurse would document this belief as what?
Grandiose delusion
A client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what? Anorexia Grandiosity Anxiety Depression
Grandiosity
A client with schizophrenia is hearing voices that tell the client to kill the self. What term is used to identify this type of false sensory perception?
Hallucination
During an admission assessment, a client with schizoaffective disorder states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. What would the nurse document this symptom as? Hallucination Delusion Avolition Alogia
Hallucination
False sensory perceptual or perceptual experiences that do not exist in reality
Hallucination Postive
Positive symptoms seen in schizophrenia are believed to be a result of which type of neurological dysfunction? Increased amount of dopamine An inadequate amount of dopamine Cerebral atrophy Organic functional changes in the brain
Increased amount of dopamine
When describing the difference between schizoaffective disorder (SAD) and schizophrenia, the nurse would address which as associated with SAD?
Increased mood responses
A client with bipolar disorder has a history of multiple episodes and states, "I'm so frustrated with what's happened because of these episodes." Which would the nurse encourage to help support this client's recovery? Codependence Hope Self-control Independent decision making
Hope
A nurse is caring for a client with major depression. The client tells the nurse that the client "just isn't sure that life is worth living." The nurse documents which nursing diagnosis as the priority?
Hopelessness related to symptoms of depression
A period of abnormally and persistently elevated, expansive or irritable mood lasting 4 days; does not impair the ability to function and does not involve psychotic features
Hypomania
Clients diagnosed with schizophrenia may experience disordered water balance that may lead to water intoxication. Which may occur as a result of water intoxication? Hyponatremia Hypernatremia Oliguria Weight loss
Hyponatremia
While caring for a client in the hospital, the nurse becomes concerned that the client may be having thoughts of suicide. Which statement would be most therapeutic?
I've noticed something is bothering you. Please share you thoughts with me."
A client is watching the news and tells the nurse that the newscaster is sending a message to the client. What term is used to identify this symptom? Idea of reference Delusion Hallucination Flight of idea
Idea of reference
A client with delusions presents with strong defensiveness, even when watching the news or listening to the radio. The nurse would document this finding in the health history as what? Ambivalence Ideas of reference Flight of ideas Echolalia
Ideas of reference
False impressions that external events have special meaning for the person
Ideas of reference Positive
The nurse is preparing to discharge a client from the inpatient facility where the client was treated following an unsuccessful suicide attempt. The priority assessment for the nurse to make is to assess whether or not the client can do what? Identify a person to whom he or she can turn to for help after discharge. Understand the need for daily medications. Feel stigmatized by the hospitalization experience. Complete activities of daily living independently.
Identify a person to whom he or she can turn to for help after discharge.
A mental health nurse is caring for a client with a diagnosis of schizophrenia. The client presents with catatonia. Which clinical manifestations should the nurse expect? Uninhibited behavior Perseveration Immobility Echopraxia
Immobility
Catatonia as seen in clients with schizophrenia is unique in the existence of which feature?
Immobility like being in a trance
A client with schizophrenia is exhibiting emotional withdrawal and poor eye contact. The mental health nurse knows that these symptoms are suggestive of which neurotransmitter imbalance? Decreased serotonin and dopamine Increased histamine Increased GABA Increased serotonin and dopamine
Increased serotonin and dopamine
Which is the central focus of persecutory delusions? Injustice that must be remedied by legal action Involving bodily functions or sensations Unfaithfulness A great, unrecognized talent
Injustice that must be remedied by legal action
To care for an acutely suicidal client, which is the most effective initial mode of treatment? Inpatient care Group therapy Behavioral therapy Outpatient care
Inpatient care
The nurse is providing teaching to a client diagnosed with schizoaffective disorder. The nurse should explain to the client that which is true about this disorder? It is more common than schizophrenia. It is usually diagnosed in late adulthood. It is most common with somatoform disorders. It is a mix of psychotic and mood symptoms.
It is a mix of psychotic and mood symptoms.
A student nurse has been assigned to provide care for an inpatient psychiatric-mental health client who has a diagnosis of schizophrenia. The student nurse is apprehensive about interacting with the client. The client's detailed explanations of the client's delusions accompanied by unpredictable movements have prompted fear in the student. How should this nursing student interpret such feelings?
It is natural to feel fear when a client exhibits unpredictable behavior, and this can cause the student to be reasonably cautious.
A psychiatric-mental health nurse is conducting a suicide assessment with a client. Why is it important to conduct a lethality assessment? It may assist in determining an individual's past suicide behaviors. It may assist in determining how long a client has been contemplating suicide. It may assist in evaluating the potential suicide protective factors of a client. It may assist in predicting how likely a person is to die by suicide.
It may assist in predicting how likely a person is to die by suicide.
Environmental factors may be associated with suicidal behavior. Which is an environmental factor? Spinal cord injury HIV infection Pain Job loss
Job loss
A 56-year-old client who suffers from seasonal affective disorder is being assessed by the nurse in an outpatient mental health clinic. The nurse is aware which treatment is the most effective type of treatment for this condition? Antidepressant therapy Psychotherapy Electroconvulsive therapy Light therapy
Light therapy
A client diagnosed with bipolar disorder and experiencing mania is admitted to the inpatient psychiatric setting. During the acute phase of mania, which medication(s) would the nurse expect to administer? Select all that apply. Lithium carbonate Carbamazepine Fluoxetine Paroxetine Divalproex sodium
Lithium carbonate Carbamazepine Divalproex sodium
A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy?
Liver function
Which has not been proposed as a potential mechanism for the etiology of thought disorders? Genetic predispositions Dysregulation of neurotransmitter systems Neglect in childhood Hemispheric brain dysfunction
Neglect in childhood
A client with bipolar disorder is prescribed divalproex sodium as part of the treatment plan. Before administering the medication, which tests should be done? Select all that apply. Liver function tests Complete blood count Platelet count Urinalysis Blood glucose concentration
Liver function tests Complete blood count Platelet count
A nurse is caring for a client diagnosed with a delusional disorder. While assessing this client, which would a nurse expect to find? History of chronic major depression Consistent disruptive behavior patterns Verbalization of bizarre delusions Living with one or more delusions for a period of time
Living with one or more delusions for a period of time
A client with severe depression has experienced anhedonia for the past 3 months. The nurse caring for this client understands that this term describes what?
Loss of interest or pleasure
Episode lasts at least 2 weeks with loss of pleasure in nearly all activities with other symptoms which may include: anhedonia, change in weight, sleep, energy, concentration, and decision making SIGE CAPS
Major Depressive Disorder
A mental health nurse is caring for a depressed client, whose spouse passed away 2 months ago. The client sates, "I'm going to kill myself." Which is a behavioral sign of suicide? Hopelessness Making a will Isolation Guilt
Making a will
A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the highest risk for a suicide attempt?
Man with major depressive disorder
A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what? Antisocial personality disorder Acute confusion Mania Chronic low self-esteem
Mania
A distinct period during which mood is abnormally and persistently elevated, expansive or irritable
Mania
Limit setting is most appropriate in which client population? Manic Anxious Depressed Suicidal
Manic
The nurse is assigned to a client with catatonic schizophrenia. Which intervention should the nurse include in the client's care plan? Meeting all of the client's physical needs Giving the client an opportunity to express concerns Administering lithium carbonate as prescribed Providing a quiet environment where the client can be alone
Meeting all of the client's physical needs
The nurse is developing a plan for group therapy sessions for several adult clients with schizophrenia. Which goal is best for this group? Members will gain insight into unconscious factors that contribute to their illness. Members will demonstrate adaptive social skills. Members will explore situations that trigger hostility and anger. Members will learn to manage delusional thinking.
Members will demonstrate adaptive social skills.
A client has been diagnosed with major depression. The client reports that the client often wakes up during the night and has trouble returning to sleep. The nurse interprets this finding as suggesting what? Initial insomnia Terminal insomnia Hypersomnia Middle insomnia
Middle insomnia
Cognitive psychotherapy is most likely to be appropriate in the care of a client who has been diagnosed with what? Anaclitic depression Moderate depression A mood disorder due to a general medical condition Postpartum psychosis
Moderate depression
A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect?
Moderate lithium toxicity
A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention? Monitoring phototherapy response. Monitoring blood levels of the medication. Teaching the client to avoid foods with tyramine. Assessing for post-electroconvulsive therapy disorientation and confusion.
Monitoring blood levels of the medication.
Schizoaffective disorder has symptoms typical of both schizophrenia and which type of disorder? Mood disorders Anxiety disorders Substance use disorders Eating disorders
Mood disorders
A nursing instructor is developing an education plan for a group of students about schizophrenia and schizoaffective disorders. The instructor identifies that in addition to psychosis, what other condition must be present at the same time for a diagnosis of schizoaffective disorder?
Mood disturbance
Which medication classification is considered first-line drug therapy for bipolar disorder?
Mood stabilizers
A comprehensive nursing assessment for neuroleptic malignant syndrome (NMS) should include checking for which in a client taking an antipsychotic medication? Headache, muscle aches, and paresthesias Confusion, giddiness, and hyperalertness Muscular rigidity, tremors, and difficulty swallowing Dry mouth, flushing, and urinary retention
Muscular rigidity, tremors, and difficulty swallowing
The nurse must be aware that individuals from diverse ethnic groups might describe troubling experiences in terms of physical problems or specific culture-bound syndromes. The syndrome of ghost sickness is exhibited by which culture?
Native American
Flat affect, lack of violation, social withdrawal or discomfort
Negative
A client had been withdrawn in the client's room for 3 days, not eating or sleeping, prior to his admission to the inpatient unit. Upon interview, the client demonstrates difficulty answering questions, appears to have no facial expressions, and cannot follow simple instructions. This cluster of symptoms can be described as what?
Negative symptoms
A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?
Orthostatic hypotension
A nurse is reviewing the medical record of a client with bipolar disorder. The nurse would most likely expect to find a history of what? Panic disorder Schizophrenia Delusional disorder Posttraumatic stress disorder
Panic disorder
While conducting a mental status examination, the client accuses the nurse of recording the interview so that it can be sent to the Federal Bureau of Investigation. What type of delusion is this client experiencing?
Paranoid
A newly admitted client's history includes multiple suicide attempts. How can the nurse on the psychiatric-mental health unit best protect the client's safety?
Performing vigilant assessment and close observation
A 44-year-old client has been experiencing intense job stress. In recent weeks, the client has confided in the client's spouse that the client believes the client's firm monitors every aspect of the client's personal performance and that the firm is engaged in deception and cover-up of its "true purpose." A nurse would recognize that the primary theme of the client's delusional disorder is what? Grandiose Somatic Conjugal Persecutory
Persecutory
A client with delusional disorder believes that the cook at the psychiatric hospital is trying to poison the client. The nurse would record this type of delusion as what?
Persecutory
A mental health client insists that the client's spouse is trying to poison the client. In this instance, the client is exhibiting which type of delusion?
Persecutory
After teaching a class of nursing students about the different types of delusions, the instructor determines that the education was successful when the class identifies which type as most common? Persecutory Somatic Grandiose Erotomanic
Persecutory
While being assessed, a client with schizophrenia states, "Everywhere I turn, the government is watching me because I know too much. They are afraid that I might go public with the information about all those conspiracies." The nurse interprets this statement as indicating which type of delusion? Grandiose Nihilistic Persecutory Somatic
Persecutory
Which type of delusion refers to a situation whereby a person or someone close to person is being malevolently treated in some way? Grandiose type Persecutory type Somatic type Unspecified type
Persecutory type
Persistent adherence to a single idea or topic, verbal repetition of a sentence, word or phrase; resisting attempts to change the topic
Perseveration Postive
A client is admitted to a mental health unit with reports of fatigue, poor appetite, and difficulty making decisions. The client also states feeling unhappy most of the time for "as long as the client can remember." Which diagnosis should the nurse anticipate for this client? Persistent depressive disorder Bipolar disorder Rapid cycling disorder Mild depressive disorder
Persistent depressive disorder
A client on the inpatient psychiatric-mental health unit was discovered attempting to asphyxiate himself or herself using a blanket. Which measure should the care team prioritize in the client's immediate care? Assessing the specific motivation for the client's attempted suicide Placing the client under constant observation Teaching the client improved coping skills Managing the client's anxiety
Placing the client under constant observation
Police officers bring a client to the mental health unit for admission. The client had been directing traffic on a busy city street, shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came close to the client. When the client's spouse is contacted at work, the spouse reports that the client stopped taking lithium 3 weeks ago and has not slept or eaten for 3 days. With which two features characteristic of the manic phase of bipolar disorder can the nurse identify?
Poor judgment and hyperactivity
A client with major depression and a suicide attempt is admitted to the inpatient facility. The client is started on antidepressant therapy. The next day, the client demonstrates significantly higher energy and says, "I'll feel much better." The nurse would interpret this behavior as suggesting what? Possible decision to complete a suicide attempt Effectiveness of the drug therapy An act to cover up the client's true feelings A typical response to the medication
Possible decision to complete a suicide attempt
Delusions, hallucinations, grossly disorganized thinking speech, behavior
Postive
The nurse is assessing a client who gave birth to a baby 1 week ago. She has been feeling sad, fatigued, and has been crying often. The client is most likely experiencing what? Dysthymic disorder Postpartum depression Major depression Postpartum blues
Postpartum blues
A 27-year-old woman has a 4-month-old baby. For the past 3 months, the client has been experiencing intense sadness, anxiety, and hopelessness. After having thoughts of killing her baby, she decided to seek help. What is the likely the cause of this client's experience? Dysthymic disorder Postpartum depression Major depression Postpartum blues
Postpartum depression
Unrelenting, rapid, often loud talking without pauses
Pressured Speech
A client was admitted to the psychiatric unit after being picked up by police officers who found the client frantically running back and forth across the freeway. The client's spouse reports that the client stayed up all night, ate very little, and talked incessantly. Additional assessment findings that indicate a manic episode include what?
Pressured speech, combative behavior, and impaired judgment
Which is the greatest predictor of a future suicide attempt?
Previous attempt
A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, "What might predict the possibility of future suicide attempts?" Which would the nurse include in the response?
Previous suicide attempt
A client has admitted to the nurse that the client is "tempted to end it all." How can the nurse prevent a future malpractice lawsuit if the client makes a suicide attempt?
Promptly act on, and document, the client's statement.
A client with delusional disorder is hospitalized. The most common reason for this is what?
Protect the client legally
A client with a diagnosis of schizophrenia has a history of auditory and visual hallucinations. Which intervention is most likely to minimize the client's hallucinations? Ensuring that the client does not sleep more than 7 hours in any 24-hour period Clustering the client's medications at 0800 hours Providing a vivid, bright environment that provides distractions from hallucinations Provide frequent contact and communication with the client
Provide frequent contact and communication with the client
A client with bipolar disorder is experiencing acute mania. The client is unable to sit still, moving from place to place. Medication therapy has been prescribed but not yet initiated. Which would the nurse include in the plan of care to meet the client's physical needs? Instituting a sleep hygiene program Providing high energy snacks Encouraging frequent rest periods Increasing environmental stimuli
Providing high energy snacks
A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring?
Pseudoparkinsonism
Shuffling gait, masklike facies, muscle stiffness, cogwheel rigidity, drooling
Pseudoparkinsonism
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would expect to assess what? Increased focus Decreased complaints of pain Psychomotor retardation Increased energy level
Psychomotor retardation
After teaching a class on antipsychotic agents, the instructor determines that the education was successful when the class identifies which as an example of a second-generation antipsychotic agent? Fluphenazine Thiothixene Quetiapine Chlorpromazine
Quetiapine
Pharmacotherapy is essential to the management of the client with bipolar disorder. The nurse understands that the goals for such therapy are what? Select all that apply.
Rapid control of symptoms Decreased frequency of manic episodes Prevention of future episodes Decreased severity of manic episodes
In the past year, a client's parent reports the client has experienced six manic episodes, each lasting for 3 weeks. This is best described as what? Rapid cycling Cyclothymic disorder Hypomania Hypermania
Rapid cycling
A client with bipolar disorder is currently experiencing mania. The nurse identifies a nursing diagnosis of sleep deprivation related to the effects of the mania. Which would be most appropriate for the nurse to include in the client's plan of care?
Reducing environmental stimuli
A client with schizoaffective disorder (SAD) is prescribed clozapine. The nurse understands that in addition to the drug's antipsychotic effects, it is also effective in which area? Limiting the risk for extrapyramidal adverse effects Reducing the risk for suicide Eliminating the need for additional medications Requiring no physiological monitoring
Reducing the risk for suicide
A client has been prescribed clozapine for schizoaffective disorder (SCA) with depression. The nurse should explain to the client that one advantage of clozapine is that it can provide what? Cost savings Weight loss Reduction of hospitalizations and risk for suicide Combination with lithium for greater effect
Reduction of hospitalizations and risk for suicide
A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder? Prodromal phase Acute illness Stabilization Relapse
Relapse
The nurse is caring for a client with major depressive disorder who has been admitted to a psychiatric-mental health facility. After assessing the client, the nurse has developed a nursing diagnosis of "risk for violence toward others related to agitation and low tolerance level." Which would be an appropriate intervention for this client? Encourage the client to engage in calming group activities. Remove all dangerous items from the client's room. Provide antianxiety medication to prevent an incident. Encourage the client to act on thoughts that are leading to aggression.
Remove all dangerous items from the client's room.
After assessing a client, the nurse identifies that the client is at risk for suicide. Which would be the nurse's priority intervention? Communicate a desire to help the client. Remove means of suicide from the client's access. Determine the course of the client's suicidal thoughts. Provide mood-stabilizing medications per physician order.
Remove means of suicide from the client's access.
A nurse is caring for a client diagnosed with schizophreniform disorder. The nurse demonstrates understanding of this disorder when identifying that the client is at risk for developing what? Schizophrenia Personality disorder Major depression Substance abuse
Schizophrenia
Some research has suggested that schizophreniform disorder may be an early manifestation of which other mental health condition? Delusional disorder Schizophrenia Bipolar affective disorder Schizoaffective disorder
Schizophrenia
A 24-year-old with schizophrenia and paranoid delusions is admitted to the hospital. The student nurse asks the charge nurse about what approach to take with the client, who has been exhibiting hostility and isolation. Which approach would be the most appropriate direction from the charge nurse? Inform the client that the client must receive care and you will assist the client. Greet the client by gently touching the client's arm and telling the client that the client can trust you. Respect the client's need for personal space and avoid physical contact. Tell the client that if the client does not comply with the rules, you will inform the doctor.
Respect the client's need for personal space and avoid physical contact.
After observing a bipolar client on the mental health unit, the nurse determines that the client is at risk for violence. Which would be an appropriate intervention? Ask the client to sit alone and write a letter. Restrict the client to the client's room until the client can calm down. Encourage the client to participate in an activity with other clients. Tell the client that if the client is violent, the client will be sent home.
Restrict the client to the client's room until the client can calm down.
Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?
Risk for other-directed violence
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority? Hopelessness related to recent divorce Ineffective coping related to inadequate stress management Spiritual distress related to conflicting thoughts about suicide and sin Risk for suicide related to highly lethal plan
Risk for suicide related to highly lethal plan
This disorder is often treated with light therapy
SAD (seasonal affective disorder)
A client is receiving lithium carbonate for the treatment of mania. The nurse would reinforce which teaching component regarding lithium treatment?
Schedule bloodwork for lithium levels.
A client who has a major depressive episode tells the nurse that, for the past 2 weeks, the client has been hearing voices and at times thinks that someone is following the client. A history reveals that the client has had these alternating symptoms before. The client also has experienced time with neither of these symptoms and has been able to function adequately. The nurse interprets these findings as suggesting: Paranoid schizophrenia Undifferentiated schizophrenia Brief psychotic disorder Schizoaffective disorder
Schizoaffective disorder
A 20-year-old son of a client who was diagnosed with schizophrenia at the age of 25 is concerned that he may also develop the disorder. Which statement regarding schizophrenia and genetics is true? Schizophrenia has not been G to be genetic. Schizophrenia can only be passed from a father to his children. Schizophrenia has shown a strong genetic contribution. Schizophrenia can only be passed from a mother to her children.
Schizophrenia has shown a strong genetic contribution.
What are the signs and symptoms of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders?
Schizophrenia lasts at least 6 months and includes at least 1 month of 2 or more active-phase symptoms.
When reviewing the diagnostic criteria for schizophrenia based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), which would be most accurate?
Schizophrenia lasts at least 6 months and includes at least 1 month of two or more characteristic symptoms.
When obtaining a client's history, a nurse determines that the client has been experiencing delusions and hallucinations for the past 3 months, which has caused some problems in the client's ability to function at work. The client also is exhibiting catatonic excitement, echopraxia, loose associations, and pressured speech. The nurse suspects which condition? Schizophrenia Schizoaffective disorder Brief psychotic disorder Schizophreniform disorder
Schizophreniform disorder
A client with schizophrenia is exhibiting positive and negative symptoms. The nurse anticipates that the client would be prescribed what? Stimulant Antidepressant Second generation antipsychotic First generation antipsychotic
Second generation antipsychotic
A nursing student is caring for an elderly client who is taking sertraline for depression. The instructor quizzes the student about the medication and its actions. To what classification of drugs should the student assign sertraline?
Selective serotonin reuptake inhibitor
A client with major depression is prescribed paroxetine. The nurse develops an education plan for the client based on the understanding that this drug belongs to which class of drugs?
Selective serotonin reuptake inhibitors
A nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what? Self-injury Sleep disruption Dehydration Weight loss
Self-injury
This neurotransmitter influences behavior including mood, activity, aggressiveness, irritability, cognition, and pain
Serotonin
A client hospitalized for uncontrolled manic behavior constantly belittles other clients on the general ward and is demanding special favors from the nurses. Which is the most effective nursing intervention for this client?
Set limits with specific and consistent consequences for belittling or demanding behavior.
A group of nursing students is reviewing information about other psychotic disorders. The students demonstrate understanding of this information when they identify which disorder as involving an inducer? Brief psychotic disorder Schizophreniform disorder Shared psychotic disorder Psychotic disorder attributable to a substance
Shared psychotic disorder
A client taking lithium for bipolar disorder is having mild diarrhea. The nurse informs the client that this is an example of what? Toxic effect Side effect Desired effect Therapeutic effect
Side effect
Family education concerning the safe care of a client with a history of suicide attempts includes what? Select all that apply. Signs and symptoms that indicate a mood change that could indicate the client is suicidal Information regarding the stressors that trigger the client's suicidal ideations Techniques to help the client cope with known triggers List of emergency service telephone numbers Information on how to determine if the threat of suicide is legitimate
Signs and symptoms that indicate a mood change that could indicate the client is suicidal Information regarding the stressors that trigger the client's suicidal ideations Techniques to help the client cope with known triggers List of emergency service telephone numbers
A client with a long history of schizophrenia has managed well on fluphenazine. The client reports smacking of the lips and sticking out the tongue. Based on this report, what does the nurse suspect is occurring with the client? Signs of tardive dyskinesia (TD) associated with neuroleptic medication Psychomotor agitation associated with schizophrenia Typical bizarre behavior associated with schizophrenia Anticholinergic side effect associated with neuroleptic medications
Signs of tardive dyskinesia (TD) associated with neuroleptic medication
A client with depression is admitted to an inpatient psychiatric unit. The nurse provides a unit orientation. While observing the client's unpacking, the nurse can expect the client to exhibit what? A desire to initiate conversation with roommates Expansive and dramatic movements Slow movements and flat affect Overly excited interest in the admission
Slow movements and flat affect
A client receiving lithium therapy has a plasma blood concentration of 2.2 mEq/L. Which would the nurse expect to assess? Slurred speech Fine resting hand tremor Loose stools Muscular weakness
Slurred speech
Which is a primary risk factor for suicide? Social isolation Unemployment Poverty Economic deprivation
Social isolation
A client diagnosed with delusional disorder who uses excessive health care resources most likely has which type of delusions? Somatic Jealous Nihilistic Grandiose
Somatic
A nurse is assessing a client who is reporting the sensation of "bugs crawling under the skin" and intense itching and burning. The client states, "I know bugs have invaded my body." There is no evidence to support the client's report. The nurse interprets this as which type of delusion?
Somatic
While being interviewed, a client diagnosed with a delusional disorder states, "I have this really strange odor coming out of my mouth. I stop to brush my teeth almost every hour and then rinse with mouthwash every half hour to get rid of this smell. I've seen so many doctors, and they can't tell me what's wrong." The nurse interprets the client's statement as reflecting which type of delusion?
Somatic
A client diagnosed with schizophrenia states to the nurse, "My intestines are being eaten by snakes." This statement represents which type of delusion? Somatic delusion Persecutory delusion Grandiose delusion Referential delusion
Somatic delusion
Which treatment would be inappropriate for a client with delusional disorder? Cognitive-behavioral therapy Individual therapy Somatic therapy Psychopharmacology
Somatic therapy
The nurse should consider which during a psychiatric assessment of a newly immigrated client who is being evaluated for possible religious delusions?
Some cultures hold religious beliefs that might be confused with delusional thought
A client is receiving antipsychotic therapy. When describing dystonic reactions to the client,the nurse would instruct the client to cf: Spasms of the eye muscles Restlessness Lip smacking Facial grimacing
Spasms of the eye muscles
A nurse is with an adolescent who reports nothing to live for and wishing to be dead. Which nursing action would be the priority? Going to the client's psychiatrist to report the suicidal ideation Staying with the client to explore more of the client's thoughts about suicide Putting the client in seclusion with a staff member assigned to watch the client at all times Ascertaining the client's beliefs about what happens when you die
Staying with the client to explore more of the client's thoughts about suicide
In a therapy session, a client with a diagnosis of major depression admits to the nurse-therapist, "I actually went out driving on the interstate this morning and had every intention of getting up to speed and plowing right into the overpass by my exit. Maybe tomorrow." The nurse would recognize the client's statement as what? Suicidal ideation Suicidal intent Suicidal gesture Suicidal threat
Suicidal intent
A parent of four small children lost a spouse in an automobile accident 3 months ago and is admitted to the hospital with severe depression. Since the spouse's death, the client's mood has been somber; until now, the client has refused treatment. What is this client at high risk for? Bipolar disorder Suicide Schizophrenia Dysthymic disorder
Suicide
When developing the plan of care for a client with schizophrenia who is in the acute phase of illness, the nurse understands that the client is at high risk for what?
Suicide
Which would be most important to assess and document in a client with depression? Appetite Weight changes Sleep disturbance Suicide risk
Suicide risk
Although a psychotic episode can be brief, the client impact can last a long time. For this reason, the nurse is aware of what? The best outcomes are achieved on an outpatient basis Family supports are required Supervision may be required to protect the person Cognitive therapy is indicated
Supervision may be required to protect the person
A client with command auditory hallucinations and a history of aggressive outbursts is observed pacing and grimacing while in the day room. Which should be the nurse's priority? Support the client in returning to the client's room Ask the client why the client appears to be agitated Turn off the dayroom's television Request that the other clients leave the dayroom
Support the client in returning to the client's room
A 55-year-old client was admitted to the psychiatric unit after an incident in a department store in which the client accused a sales clerk of following the client around the store and stealing the client's keys. The client was subdued by the police after destroying a window display because voices had told the client that it was evil. As the nurse approached the client, the client says, "You're all out to get me, and you're one of them. They're Rostoputians and grog babies here." This demonstrates what? Loose associations and flight of ideas Suspiciousness and neologisms Illusions and loss of ego boundaries Echolalia and echopraxia
Suspiciousness and neologisms
A client comes to the clinic for an evaluation. During the interview, the client states that the client feels insects crawling all over the skin on the client's arms and legs. The nurse interprets this as which type of sensorium or processing deficit?
Tactile hallucination
Abnormal involuntary movement, ex: lip smacking, tongue protrusion, chewing, blinking, grimacing
Tardive Dyskinesia
A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which extrapyramidal side effects (EPS)? Tardive dyskinesia Dystonia Neuroleptic malignant syndrome Akathisia
Tardive dyskinesia
A nurse is caring for a client who has been receiving treatment for schizophrenia with chlorpromazine for the past year. It would be essential for the nurse to monitor the client for what?
Tardive dyskinesia
Nursing Intervention: Assess using tool such as AIMS; report occurrence or score increase to physician.
Tardive dyskinesia
Which is an appropriate intervention for a client having auditory hallucinations? Encourage the client to discuss the content of the hallucinations with staff as they occur. Ask the client to keep a journal about what the voices tell the client and to bring the journal to therapy sessions. Encourage the client to spend quiet time alone until hallucinations cease. Tell the client to talk back to the voices and tell them to go away.
Tell the client to talk back to the voices and tell them to go away.
Which assessment findings in a client who is suspected of having a delusional disorder would be suggestive of a diagnosis of schizophrenia?
The client experiences frequent and sustained hallucinations.
The nurse is assessing a client for warning signs of suicide. Which would be a concern?
The client has engaged in risky behaviors and tends to be impulsive.
The nurse is working with an inpatient who has a history of suicide attempts. What action by the client should the nurse follow up on because it may constitute a suicide planning behavior?
The client has requested extra bedding despite the warm weather
The nurse is evaluating the plan of care for a client with schizophrenia. Which observation best suggests that the plan has been effective? The client no longer believes that the client has special powers. The client has resumed employment and has been attending social functions at the community center. The client reports that the client no longer has hallucinations. The client has been engaging in more conversation with the staff.
The client has resumed employment and has been attending social functions at the community center.
A client has been treated following a suicide attempt. When providing anticipatory guidance during the client's discharge education, the nurse should teach the client that: The client is likely to experience stigma around the suicide attempt from some people. The client's commitment to treatment statement will be in effect for the next 6 months. A subsequent suicide attempt will likely cause the client to be declared legally incompetent. The client's long-term recovery will be primarily dependent on the adherence to group therapy.
The client is likely to experience stigma around the suicide attempt from some people.
The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide?
The client overdosed on pills 2 years earlier
The nurse is working with an outpatient who has a history of depression and suicide attempts. What assessment finding should the nurse interpret as indicating a high degree of planning for a future attempt? The client recently purchased a large bottle of over-the-counter analgesics The client stopped attending a depression support group, despite initially benefiting from it The client told the nurse, "I just want to stop being a burden to my wife and kids." The client has told the nurse, "I'm pretty sure my meds aren't working."
The client recently purchased a large bottle of over-the-counter analgesics
The client's diagnosis of schizoaffective disorder is supported when the nurse documents what?
The client reports "hearing voices" for the last 3 months
The nurse is performing an assessment of a client with depression. It took more than four sessions to complete. What is the likely reason for needing multiple sessions? The client was unwilling to answer the nurse's questions. The client was too tired to answer all of the nurse's questions in one session. The client had an insufficient attention span to understand and answer the nurse's questions. The client had impaired cognition leading to the inability to answer the nurse's questions.
The client was too tired to answer all of the nurse's questions in one session.
A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what?
The client will demonstrate improved ability to express self.
A client with a delusional disorder has been undergoing individual psychotherapy. The therapy would be deemed ultimately successful when the client meets which outcome? The client will identify alternatives to present coping patterns. The client will describe problems relating to others. The client will identify situations that evoke anxiety. The client will differentiate between reality and fantasy.
The client will differentiate between reality and fantasy.
A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what?
The client will reframe negative thoughts in a more positive way.
Research related to the development of schizophrenia has shown what? The likelihood of developing schizophrenia for a sibling of a person with the disorder is less than that of individuals in the general population. The disorder is thought to arise from the interaction of a biological predisposition and environmental stressors. Behavioral family pathology, not genetics, is the primary risk factor for the development of schizophrenia. If an identical twin develops schizophrenia, the other twin will also develop the disorder.
The disorder is thought to arise from the interaction of a biological predisposition and environmental stressors.
A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching?
The higher the sodium level, the lower the lithium level will be.
When teaching a group of new mental health nurses about the major difference between bipolar I and bipolar II disorders, which would be most appropriate for the nurse to include? Unlike bipolar II, bipolar I disorder involves no symptoms of mania, but only depression. Bipolar II is more often recognized than bipolar I. The mania symptoms of bipolar II disorder have little effect on functioning. Both disorders are the same, except the risk for suicide is greater with bipolar I disorder.
The mania symptoms of bipolar II disorder have little effect on functioning.
A novice nurse on a psychiatric unit may find it challenging to care for a client newly diagnosed with schizophrenia primarily for which reason? The nurse may feel defensive when a delusional client makes accusations The client will only likely be seen for a one-time admission The characteristic disintegration of the client's personality is difficult to watch The nurse worries about developing schizophrenia
The nurse may feel defensive when a delusional client makes accusations
Which would be the benefit of including a client's family members in the long-term treatment of a client with schizophrenia? The onset of a possible relapse can be detected early and effective treatment can be initiated It shows the client that he/she is loved and so it elevates the client's self-esteem The client's compliance with treatment can be monitored and supported effectively The family can provide more effective care when it is based on an understanding of the disease
The onset of a possible relapse can be detected early and effective treatment can be initiated
A client with major depression has been prescribed escitalopram. The nurse should address what topic in client education? The possibility of gastrointestinal upset The need to avoid food containing tyramine Strategies for preventing orthostatic hypotension The possibility of weight loss
The possibility of gastrointestinal upset
After being prescribed several medications that were ineffective, a client is diagnosed with refractory mania. The physician decides to prescribe lamotrigine, an anticonvulsant that has been found to be effective for refractory mania. Which would the nurse need to include in the client's education plan? The potential for life-threatening side effects such as Stevens-Johnson syndrome The potential for the development of addiction to the medication The need to have blood levels drawn on a monthly basis The need to avoid certain types of foods while on the medication
The potential for life-threatening side effects such as Stevens-Johnson syndrome
A client with schizophrenia is prescribed an antipsychotic medication. Which immediate side effects would the nurse include in the education plan for this medication? Risk for hypertension Risk for hypoprolactinemia The potential for weight loss The potential for sedation
The potential for sedation
Which data support a nursing diagnosis of impaired verbal communication? Ambivalence, delusional thinking, and avolition The presence of neologism, echolalia, and clanging The presence of neologism, delusions, and anergia Rapid pacing and running
The presence of neologism, echolalia, and clanging
A nurse is developing a presentation for families who have members who have been diagnosed with bipolar disorders. When describing this condition to the group, which would the nurse most likely include? As the person ages, the episodes tend to decrease. Environmental stressors are a key cause of these disorders. The risk for suicide is high with either depression or mania. Risk-taking behaviors are more common during a depressive episode.
The risk for suicide is high with either depression or mania.
Which statement most accurately describes the relationship between psychiatric illness and suicide risk? Psychiatric-mental health clients are stereotyped as being at high risk of suicide, but this is untrue. The vast majority of people who commit suicide have a diagnosed mental disorder. Clients with depression are at increased risk of suicide, but suicide rates among persons with schizophrenia equal those of the general population. According to the DSM-5, suicide is considered to be a psychiatric diagnosis in and of itself.
The vast majority of people who commit suicide have a diagnosed mental disorder.
Which is an accurate statement regarding women and suicide?
They are less likely to complete suicide than men.
A psychiatric-mental health nurse is teaching a class about schizophrenia. When describing delusions, which information would the nurse <b>most</b> likely include? They are variable in nature. They are easily changed with conflicting evidence. They could be a real-life situation. They are implausible within the person's ethnic background.
They could be a real-life situation.
When assessing a client with a delusional disorder who is experiencing somatic delusions, which would the nurse expect as within normal parameters? Select all that apply. Thinking Orientation Self-care patterns Attention Sleep patterns
Thinking Orientation Attention
Which best defines the term suicide?
Thinking about and planning one's own death
A client states, "My boss keeps putting thoughts into my head. Yesterday my boss made me copy 25 reports and then told me I had wasted company time and money!" The nurse knows the client is experiencing which perceptual disturbance? Thought withdrawal Thought blocking Thought insertion Thought broadcasting
Thought insertion
A 51-year-old client with a history of an alcohol use disorder and depression has committed suicide. The care team has subsequently taken steps to organize a postvention. What is the goal of a postvention? To provide a chance for the client's family and friends to reminisce about the client. To allow the client's family and other close acquaintances to express their feelings about the suicide. To identify the clues that should have been acted upon in the days leading up to the client's suicide. To teach the client's close friends and family coping skills that they will need in the months ahead.
To allow the client's family and other close acquaintances to express their feelings about the suicide.
A client is diagnosed with a delusional disorder. While providing care to the client, the nurse assesses the client's delusions. Which would be least appropriate for the nurse to do?
Try to change the client's delusional belief
Which statements characterizes the major difference between the typical and atypical antipsychotic medications? Typical antipsychotics most often relieve positive symptoms but do not have a significant impact on negative symptoms. Atypical antipsychotics relieve only negative symptoms. Atypical antipsychotics tend to cause many more extrapyramidal side effects than do the typical antipsychotics. Typical antipsychotics cause blood dyscrasias, whereas atypical ones do not.
Typical antipsychotics most often relieve positive symptoms but do not have a significant impact on negative symptoms.
A nurse is reviewing the medical record of a patient to determine the patient's risk for suicide. Which factor would alert the nurse to an increased risk for this patient? Fear of growing older Acute illness Homosexuality issues Unemployment
Unemployment
When caring for a client with mania, which would the nurse most likely assess? Unusual self-confidence Slow, repetitive speech Logical thinking Narrowed focus
Unusual self-confidence
A client diagnosed with schizophrenia states, "I want to go home, go home, go home." This is an example of which speech pattern? Verbigeration Clang association Neologisms Word salad
Verbigeration
Which is a nonneurologic side effect of antipsychotic medications? Weight gain Akathisia Dystonia Seizures
Weight gain
Assessment of genetic predisposition supports asking a client who is exhibiting symptoms of a delusional disorder what? Whether any family members have been diagnosed with schizophrenia When the delusion first began If the client has complied with the treatment plan If any family member shows symptoms of depression
Whether any family members have been diagnosed with schizophrenia
A nurse is caring for a client who has been taking clozapine for 2 weeks. The client tells the nurse, "My throat is sore, and I feel weak." The nurse assesses the client's vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?
White blood cell count
A client has been prescribed clozapine for treatment of schizophrenia. The client must be taught to monitor which blood concentrations weekly while taking this drug?
White blood cells
A client taking lithium for bipolar disorder comes to the clinic and reports symptoms which the nurse interprets as consistent with moderate lithium toxicity. Which action should the nurse perform? Select all that apply. Withhold additional doses of lithium. Obtain a blood sample for lithium level. Perform a 12-lead electrocardiogram. Push fluids. Contact the physician.
Withhold additional doses of lithium. Obtain a blood sample for lithium level. Push fluids. Contact the physician.
When conducting a suicide risk assessment, the nurse understands that which method has the least lethality? Hanging Wrist slashing Overdose of benzodiazepines Jumping
Wrist slashing
A client is being screened for clinical symptoms related to depression over the past 2 weeks. Which self-assessment screening instruments would be most appropriate? Zung Self-Assessment Scale Beck Depression Inventory Hamilton Rating Scale for Depression Geriatric Depression Scale
Zung Self-Assessment Scale
The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ... assess for depression in the client's family history. prepare the client for diagnostic genetic testing to confirm the diagnosis. educate the client regarding the symptoms of related physical disorders. encourage the client to seek genetic counseling before considering a pregnancy.
assess for depression in the client's family history.
During assessment of a client with depression, the client states, "I just feel so sad and hopeless. I just don't care anymore. I don't even enjoy doing the crossword puzzles like I used to." The nurse documents this finding as indicative of: dysthymic disorder. anhedonia. delusion. psychosis.
anhedonia
A client with schizoaffective disorder is prescribed medication therapy. Which type of medications would be most likely be ordered? atypical antipsychotics typical antipsychotics antidepressants mood stabilizers
atypical antipsychotics
A nurse is interviewing a client with schizophrenia when the client begins to say, "Kite, night, right, height, fright." The nurse documents this as: clang association . stilted language. verbigeration. neologisms.
clang association
A nursing instructor is preparing a class lecture about schizophrenia and outcomes focusing on recovery. Which would the instructor include as a major goal? continuity of care shorter inpatient stays immediate crisis stabilization social engagement
continuity of care
A nurse taking an admission history from a client suspects that the physician will diagnose major depression. For the physician to make this diagnosis, the client will have to demonstrate specific symptoms. What are some of these symptoms? Select all that apply. disruption in sleep disruption in appetite obsessive desire to exercise disruption in concentration excessive guilt
disruption in sleep disruption in appetite disruption in concentration excessive guilt
A nurse is caring for a client in an inpatient mental health setting. The nurse notices that when the client is conversing with other clients, the client repeats what they are saying word for word. The nurse interprets this finding and documents it as: echopraxia. neologisms. tangentiality. echolalia.
echolalia
A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the education was effective when they state that which should be reported immediately? elevated temperature tremor decreased blood pressure weight gain
elevated temperature
When investigating biologic theories related to schizophrenia, which neuroanatomic findings would be consistent with this mental health disorder? enlarged lateral ventricle enlarged brain volume smaller third ventricle enlarged hippocampus
enlarged lateral ventricle
When assessing a person with delusional disorder, which finding would the nurse expect to assess? few, if any, psychological deficits changes in mental status altered personality high level of intelligence
few, if any, psychological deficits
The majority of suicides among men are attributed to: firearms. hanging. overdose. drowning.
firearms
A client diagnosed with delusional disorder is telling everyone that the client is the president of the United States. This client is exhibiting which type of delusion? grandiose erotomanic somatic jealous
grandiose
While caring for a hospitalized client with schizophrenia, a nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to the client. The nurse interprets this finding as: autistic thinking. concrete thinking. referential thinking. illusional thinking.
referential thinking.
A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should ...
help the client to identify and explore other options.
A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of: hypotension. nausea. weight loss. infection.
infection
A group of nursing students is reviewing information about suicide and associated concepts. The group demonstrates understanding of the information when members identify which as the probability that a person will successfully complete suicide? parasuicide suicidal ideation suicidality lethality
lethality
A client diagnosed with schizophrenia is having delusions that the client is being plotted against by the government. This would be documented as which type of delusion? persecutory grandiose nihilistic somatic
persecutory
A client who has attempted suicide has an underlying diagnosis of depression. Which would the nurse anticipate being ordered for the client? selective serotonin reuptake inhibitor mood stabilizer tricyclic antidepressant atypical antipsychotic
selective serotonin reuptake inhibitor
When assessing risk of suicide, which are important assessment components? Select all that apply. seriousness of suicidal ideation degree of hopelessness previous attempt lethality of method Unemployment
seriousness of suicidal ideation degree of hopelessness previous attempt lethality of method
A nurse is providing a presentation about suicide for a group of health professionals. Which would the nurse address as a major contributing factor to the rising suicide rate among men? substance abuse media influences lack of conflict resolution skills parenting practices
substance abuse
When assessing a client who reports mild symptoms of depression, the nurse expects that the diagnostic tests ordered will include: thyroid stimulating hormone (TSH). coagulation time. platelet count. liver function test
thyroid stimulating hormone (TSH).