Exam 2 Questions

ANS: B The nurse must assess the patient's access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the patient's safety. The information in the other questions may be important to ask but are not the most critical.

Select the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills. a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

ANS: C If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

When assessing a patient's plan for suicide, what aspect has priority? a. Patient's financial and educational status b. Patient's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of patient's social support

ANS: B Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

Which statement by a depressed patient will alert the nurse to the patient's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."

A Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine. Complications of SNRI include hypomania, orthostatic hypotension, hypertensive crisis.

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "Should tell the client about the likelihood of insomnia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."

C The client is at greatest risk for suicide during the acute phase of MDD. The focus of the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD. The maintenance phase of treatment for MDD can last for one year or more. Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD.

A charge nurse is discussing the care of a client who has a major depressive disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD" B. "The treatment of MDD during the manifestation phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

A, C, D Positive symptoms of schizophrenia such as auditory hallucinations, delusions of grandeur, and severe agitation, are effectively treated with first-generation antipsychotics.

A charge nurse is discussing the manifestation of schizophrenia with a newly licensed nurse. Which of the following manifestations should the charge nurse identify as being effectively treated by first-generation antipsychotics? SATA A. Auditory hallucinations B. Withdrawal from social situations C. Delusion is of grandeur. D. Severe agitation E. Anhedonia

D weight gain is an expected adverse effect of paroxetine and other SSRI. Other adverse effects include nausea, headaches, insomnia, and sexual dysfunction.

A nurse is assessing a client who has a panic disorder and has been taking paroxetine, an SSRI. Which of the following assessments would the nurse identify as an adverse effect of the medication? A. Peripheral edema B. Chest congestion C. Shuffling gait D. Weight gain

C Second-generation antipsychotics such as risperidone are effective in treating negative symptoms of schizophrenia. Chlorpromazine, thiothixene, and haloperidol are all first-generation antipsychotics and are used mainly to control positive, rather than negative, symptoms of schizophrenia.

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat affect. The nurse should expect a prescription for which of the following medications? A. Chlorpromazine B. Thiothixene C. Risperidone D. Haloperidol

A Routine monitoring of liver function test is necessary due to the risk of hepatotoxicity

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Blood sodium and potassium

D The client is demonstrating associative looseness, a pattern of disordered speech that reflects haphazard and illogical thoughts. With clang association, the sound rather than the meaning of word drives the client's speech pattern. With echolalia, the client continues to repeat the word or statements of another individual. With word salad, the client uses individual words to construct incoherent sentences without meaning.

A nurse is observing a client with schizophrenia in the day room. Another client asks him if several items of clothing match. He replies, "A match. I like matches. They are the givers of light, the light of the world. Let your light shine on." The nurse should identify these statements as which of the following speech alterations? A. Clang association B. Echolalia C. Word salad D. Associative looseness

A The nurse should identify that all second-generation antipsychotic medications such as risperidone can cause diabetes, weight gain, and dyslipidemia. To monitor for diabetes, a baseline glucose reading should be obtained and compared to a glucose reading taken 12 weeks later. Risperidone does not affect liver enzymes, platelet count, or cause an elevated WBC count.

A nurse is reviewing laboratory reports for a client who is taking risperidone. The nurse should identify which of the following results indicate their potential adverse effect to the medication. A. Elevated blood glucose B. Elevated white blood cell count C. Decreased platelet count D. Decreased aspartate transaminase (ALT)

ANS: A, B, C One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply. a. Maintain arm's-length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the patient's eyeglasses to prevent self-injury. e. Interact with the patient every 15 minutes.

ANS: C The correct response gives the patient reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the patient's ambivalence and sets the stage for more realistic problem solving.

. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the most helpful response for a nurse to make when the patient states, "I am considering committing suicide." a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

ANS: A, C, D, E Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, "No one can understand," can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply. a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

ANS: A The parents' statements indicate guilt. Guilt is evident from the parents' self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario

A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." The parents' reaction reflects: a. guilt. b. denial. c. shame. d. rescue feelings.

A, C, E Primary interventions focus on suicide prevention through the use of community education and screenings to identify individuals at risk. Conducting a suicide risk screening on all new clients, educating high school teens about suicide prevention, and educating middle school teachers to recognize the warning indicators of suicide are all examples of a primary intervention.

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? SATA A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who complete suicide C. educating high school teens about suicide prevention D. Initiating one-on-one observation for a client who has current suicidal ideation E. teaching middle school educators about warning indicators of suicide

B A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority and initiating one-on-one observation is the first action the nurse should take.

A nurse is caring for a client in an acute mental health unit. The client reports hearing voices that are saying, "still your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in Group therapy on the unit. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

B, C, D, E depressive disorders are more common in a client who has chronic medical conditions, who is experiencing a high amount of stress, in clients who have a family history of depression, and a client who has a history of anxiety or personality disorder.

A nurse is caring for a client who has a major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? Select all that apply A. male sex B. History of chronic bronchitis C. Recent death in client's family D. Family history of depression E. Personal history of panic disorder

D The absence of something that should be present is considered a negative symptom of schizophrenia. Social discomfort, the inability to enjoy activities, or a lack of goal-directed behavior are negative symptoms of schizophrenia. The presence of something that should not be present is considered a positive symptom of schizophrenia such as delusions, hallucinations, disorganized speech, and bizarre behaviors. Cognitive symptoms are subtle and represent the third symptom group. Impairments in memory, attention, thinking, judgment, or problem-solving are considered cognitive symptoms of schizophrenia. Impaired memory impacts short term memory and the ability to learn.

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A. Hallucinations B. impaired memory C. Dysphoria D. Social discomfort

D ensure the client swallows medication to prevent hoarding of medications in an attempt to exceed the prescribed dose. Other suicide precautions include initiating one-on-one constant supervision, searching the client's belongings with the client present, the use of plastic eating utensils, ensuring the client's hands are always visible when sleeping, identifying whether the client's current medications can be lethal with exceeding the prescribed dose.

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care? A. Assign the client to a private room B. Document the client's behavior every hour C. Allow the client to keep perfume in her room D. Ensure that the client swallows the medication

B,D,E The client should be alert for sleep disturbances, which can indicate A relapse. The client who has bipolar disorder can participate in psychotherapy to help prevent relapses. The onset of anhedonia, the inability to feel pleasure, is a manifestation of depression which can indicate A relapse of bipolar disorder. The client who has bipolar disorder should avoid the use of caffeine because it can precipitate a relapse.

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? SATA A. Use caffeine in moderation to prevent relapse. B. Difficulty sleeping can induce a relapse. C. Begin taking your medications as soon as a relapse begins. D. Participating in psychotherapy can help prevent a relapse. E. Anhedonia is a manifestation of a depressive relapse.

D The nurse should instruct the client to eat a low-calorie diet while taking lithium because this medication can cause weight gain. The nurse should encourage the client to take lithium with food or milk to prevent GI upset. The nurse should instruct the client not to take NSAIDs like ibuprofen with lithium because they increase the risk of lithium toxicity. The nurse should encourage the client to maintain an adequate dietary intake of sodium. Decreased levels of sodium can result in lithium toxicity.

A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take lithium on an empty stomach." B. "I can take ibuprofen for headaches while taking lithium." C. "I need to limit my salt intake while taking lithium." D. "I am likely to gain weight while taking lithium."

C Manifestations of persistent depressive disorder lasts for at least two years in adults. MD contains a minimum of five clinical findings of depression. Wide fluctuations in mood are associated with bipolar disorder not persistent depressive disorder.

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of a minimum of five clinical findings of depression C. Presence of manifestations of at least two years D. Inflated sense of self-esteem

B Client who has cardiac arrhythmia needs further evaluation since the greatest risk of death due to ECT is related to cardiac complications

A nurse is obtaining a client's medical history prior to scheduling the client for electroconvulsive therapy (ECT). Which of the following findings should the nurse identify as a potential complication of the procedure? A. Severe depression B. Cardiac arrhythmia C. Bipolar disorder D. Parkinson's disease

B, C, E Offering concise explanations improves the clients ability to focus and comprehend the information. Establishing consistent limits decreases the risk for client manipulation. Using a firm approach with client communication promotes structure and minimizes inappropriate client behavior.

A nurse is planning care for a client who has bipolar disorder and is experiencing A manic episode. Which of the following interventions should the nurse include in the plan of care? Select all that Apply A. Provide flexible client behavior expectations. B. Offer concise explanations. C. Established consistent limits. D. Disregard client concerns. E. Use a firm approach with communication.

C Antipsychotic medications have a high risk for significant weight gain.

A nurse is providing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates an understanding of the teaching? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."

D A muscle relaxant, succinylcholine, Is administered to reduce the risk of injury during induced seizure activity. The typical course of ECT treatment is 2 to three times a week for a total of 6 to 12 treatments. ECT does not cure depression. However, it can reduce the incidence and severity of relapse. ECT is indicated for clients who have major depressive disorder and who are not responsive to pharmacological treatment.

A nurse is providing teaching for a client who is scheduled to receive ECT for treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive series of ECT treatments." C. "Should receive ECT once a week for six weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

C The greatest risk to the client is development of seizures. Bupropion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This information is the highest priority to report to the provider.the

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression B. The client currently smokes 1.5 packs of cigarettes per day C. The client has a motor vehicle crash last year and sustained a head injury new line D. the client is a BMI of 25 and has gained 10 pounds over the last year

B Ask the client directly about the hallucinations to identify client needs and assess for potential risk of injury.

A nurse is speaking with a client who has schizophrenia when the client suddenly seems to stop focusing on the nurse's question and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take? A. Stop the interview at this point and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client," You seem to be looking at something on the ceiling. I see something there too." D. Continue the interview without comment on the client's behavior.

C Clinical finding of PMD is emotional liability, the client can experience rapid changes in mood

A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect my problems with PMDD to be worse than when I'm menstruating." B. "I should avoid exercising when I'm feeling depressed." C. "I'm aware that my PMD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

ANS: C This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

ANS: D Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. The initial outcome is that the patient will: a. verbalize a will to live by the end of the second hospital day. b. describe two new coping mechanisms by the end of the third hospital day. c. accurately delineate personal strengths by the end of first week of hospitalization. d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.

ANS: C This scenario presents a potential crisis. Establishing rapport facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to: a. assess lethality of suicide plan. b. encourage expression of anger. c. establish rapport with the patient. d. determine risk factors for suicide.

ANS: A Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.

An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Desensitization techniques c. Relaxation training classes d. Use of complementary therapy

ANS: B Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication.

An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline (Elavil), a sedating tricyclic medication b. Fluoxetine (Prozac), a selective serotonin reuptake inhibitor c. Desipramine (Norpramin), a stimulating tricyclic medication d. Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

C ECT is indicated for the treatment of bipolar disorder with rapid cycling, major depressive disorder, schizophrenia disorder, and acute manic episodes.

Nurses leading a peer group discussion about the indications of ECT. Which of the following indications should the nurse include in the discussion? A. Borderline personality disorder. B. Acute withdrawal related to substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

ANS: B Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

ANS: D This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night

C, E transient short memory loss and confusion is an expected finding immediately following ECT. Disorientation occurs immediately following the procedure and can persist for several hours. Clients have retrograde amnesia which is the loss of memory of events leading up to the procedure and have no memory of the procedure. Memory loss can persist for several weeks. Whether ECT causes permanent memory loss is controversial, but most clients fully recover from any memory deficits.

In assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? SATA A. Hypotension B. paralytic ileus C. memory loss D. polyuria E. confusion

ANS: A The patient now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a suicide risk.

It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant medication. The patient is now more talkative and shows increased energy. Select the highest priority nursing intervention. a. Supervise the patient 24 hours a day. b. Begin discharge planning for the patient. c. Refer the patient to art and music therapists. d. Consider discontinuation of suicide precautions.

ANS: A Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is a. hopelessness. b. sadness. c. elation. d. anger.

A Valproic acid can cause severe hepatotoxicity and liver failure. The nurse should monitor the client's liver function at baseline and periodically thereafter. The nurse should also teach the client about the manifestations of liver failure. Valproic acid can cause nausea, vomiting, and indigestion which is minimized by taking this medication with food. Valproic acid does not cause physical dependency or any other significant central nervous system effects

The nurse is caring for a client who has bipolar disorder and a new prescription for valproic acid. Which of the following actions should the nurse take? A. Monitor the client's liver function B. Avoid giving the medication with food or milk C. Counsel the client regarding medication dependency D. Limit intake of foods containing tyramine

C The nurse should identify this statement as an indication of persecutory delusions which is feelings of being singled out for harm by others such as being hunted down by the FBI. Being killed by a tornado is an indication of nihilist delusion characterized by the delusional belief of being dead, decomposed or annihilated. In reference to television purposely playing commercials is an indication of referential delusion which misconstrues trivial events and attaches personal significance to them, such as believing that others who are discussing the next meal or talking about them.

The nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A. "A tornado is going to wipe us out in nine days." B. "My brain is dead, and my body is slowly rotting away." C. "The government is after me because I know top secret information." D. " The TV is purposely playing commercials for products I don't like."

A the greatest risk for a client who has MDD and comorbid anxiety is injury due to self harm. The highest priority intervention is placing the client on one to one observation.

The nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorders. Which of the following actions is the nurse's priority? A. Placing the client on one-to-one observation B. Assisting the client to perform ADL C. Encouraging the client to participate in counseling. D. Teaching the client about medication's adverse effects

ANS: C Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies

ANS: B Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.

Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. Gamma-aminobutyric acid deficiency

ANS: D High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with twelve grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

ANS: C Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

ANS: D This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.

Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal patient b. Referral of a formerly suicidal patient to a support group c. Suicide precautions for 24 hours for newly admitted patients d. Helping school children learn to manage stress and be resilient

ANS: A Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the patient has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

Which statement provides the best rationale for closely monitoring a severely depressed patient during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Patients who previously had suicidal thoughts need to discuss their feelings. c. For most patients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

ANS: C Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

ANS: A The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The patient often feels relieved to be able to talk about suicidal ideation.

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you became depressed."

ANS: C The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the patient who thinks "I am not going to harm myself, I am going to kill myself" or "I am not going to attempt suicide, I am going to commit suicide." A patient may call a therapist and leave the telephone to carry out the suicidal plan.

A nurse and patient construct a no-suicide contract. Select the preferable wording. a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."

ANS: C Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the patient's suicide as being a way to "fix everything" but does not say it outright.

A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

ANS: A, B, D Whites have suicide rates almost twice those of non-whites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply. a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

C Amitriptyline can cause tachycardia and ECG changes. An older adult client is at risk for cardiovascular events while using the amitriptyline; Therefore, an ECG should be performed prior to starting the therapy to obtain a baseline of the client's cardiovascular status.

A nurse caring for an older adult client who has a new prescription for amitriptyline to treat depression. Which of the following diagnostic tests should the nurse plan to perform prior to starting the client on this medication? A. Hearing Examination B. Glucose tolerance test C. Electrocardiogram D. Pulmonary function test

ANS: D The nurse helps the patient develop effective coping skills. Assist the patient to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."

D Diuretics such as furosemide are contraindicated for use with lithium due to the risk for toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting medical history from the client's caregiver, which of the following statements is the priority to report to the provider? A. "Current medical conditions include diabetes that is controlled by diet." B. "Recent medications include a course of Prednisone for acute bronchitis." C. "Current vaccinations include a flu vaccine last month." D. "Current medications include furosemide for congestive heart failure."

A The client is experiencing parkinsonism, which is an adverse effect of the antipsychotic medication chlorpromazine. Amantadine is an anti-parkinsonian medication used to treat the extrapyramidal manifestations that can occur with chlorpromazine therapy.

A nurse is assessing a client who has a new prescription for chlorpromazine to treat schizophrenia. The client has a mask-like facial expression and is experiencing involuntary movements and tremors. Which of the following medications should the nurse anticipate administering? A. Amantadine B. Bupropion C. Phenelzine D. Hydroxyzine

D The client is experiencing extrapyramidal effects of thioridazine, which includes pseudo-parkinsonism. Benztropine is a medication that counteracts these adverse effects. The nurse should notify the provider if extrapyramidal effects occur and obtain a prescription to alleviate the manifestations

A nurse is assessing a client who has been taking thioridazine hydrochloride for several days. The client reports hand tremors, drooling, and rigid extremities. Which of the following actions should the nurse take? A. Reassure the client that these effects are expected B. Administer diazepam C. Encourage deep breathing and relaxation D. Administer benztropine

A, C, E This statement is an overt comment about suicide in which the client directly talks about their perception of the outcome of their Death, or directly talks about their wish to no longer be alive. An overt comment is when someone directly comments about their wish for death. It is important to assess potential suicide risk using a standardized assessment tool such as the sad persons scale.

A nurse is assessing a client who has major depressive disorder. The client should identify which of the following client statements as an overt comment about suicide? SATA A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C. "I wish my life was over." D. "I don't feel like I can ever be happy again." E. "If I kill myself then my problems will go away."

A The nurse should identify a client who has schizophrenia and is experiencing delusions to demonstrate a positive symptom. Positive symptoms are seen early in clients who have schizophrenia and are easier to detect than other types of symptoms. Other positive symptoms can include hallucinations, disorganized speech, and disorganized behavior. Affective symptoms are when the client is experiencing symptoms that involve their emotions and expressions. Cognitive symptoms are when the client experiences A subtle or obvious impairment in memory, thinking, attention, or judgment.

A nurse is assessing a client who has schizophrenia and is experiencing delusions. The nurse should identify that the client is experiencing which of the following types of symptoms? A. Positive B. Cognitive C. Negative D. Affective

B, C, E drooling, involuntary arm movements, and continual pacing is an indication of extrapyramidal symptoms.

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as extrapyramidal symptoms? SATA A. Decreased level of consciousness B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing

D The nurse should expect the provider to prescribe paroxetine, an SSRI which is considered the first-line treatment for PTSD. Bupropion is an aminoketone antidepressant that is prescribed for smoking cessation, depression, and the treatment of ADHD. Phenelzine is an MAOI antidepressant that can be prescribed for PTSD. However, SSRIs such as paroxetine are the first choice. Mirtazapine is a tricyclic antidepressant that can be prescribed for PTSD however SSRI such as paroxetine are the first choice.

A nurse is assessing a client who is experiencing post-traumatic stress disorder (PTSD) following a traumatic event. Which of the following medications should the nurse expect the provider to prescribe? A. Bupropion B. Phenelzine C. Mirtazapine D. Paroxetine

D antipsychotic medications such as clozapine can cause agranulocytosis, which is the depletion of white blood cells. This increases the client's risk of infection. A fever is an early indication to the nurse to check the client's white blood cell count to detect agranulocytosis.

A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication? A. Urine specific gravity B. urine output C. blood pressure D. temperature

D Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyurea. Muscle weakness, find hand tremors, nausea, vomiting, diarrhea, and lethargy are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 to 1.5 mEq/L. Manifestations of lithium toxicity with levels above 2.5 include seizures and oliguria. For levels above 3.5 are delirium, cardiovascular collapse, coma, and death.

A nurse is assessing a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect? A. Muscle weakness B. Oliguria C. Vomiting D. Blurry vision

D Monitoring for escalating behavior addresses the clients priority need for safety and is therefore the priority nursing action.

A nurse is caring for a client who has bipolar disorder. Which of the following is a priority nursing action? A. Set consistent limits for expected client behavior. B. Administer prescribed medications as scheduled. C. Provide the client with step by step instructions during hygiene activities. D. Monitor the client for escalating behavior.

B This comment indicates the client is experiencing a loss of identity or depersonalization. Depersonalization is a nonspecific feeling that a client has lost their identity. Self is different or unreal. Stealing of thoughts Is considered thought withdrawal which is a belief that their thoughts have been removed from their mind by an outside agency.

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero, and I am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

A Orthostatic hypotension is an adverse effect of chlorpromazine. Other adverse effects include palpitations, tachycardia, constipation, sedation, and photosensitivity.

A nurse is caring for a client who has schizophrenia and a prescription for chlorpromazine. For which of the following adverse effects should the nurse monitor? A. Orthostatic hypotension B. Diarrhea C. Urinary frequency D. Bradycardia

D the nurses voicing doubt about this response, which expresses uncertainty regarding the reality of the client's conclusion of the hallucination. This is a therapeutic response because the statement allows the client to expand upon the earlier statement, which allows exploration of the client's thought processes. The response in regards to the laboratory technician is interpreting the client's meaning into something that seems more plausible to the nurse. This invalidates the client's thoughts and statements, which is non-therapeutic..

A nurse is caring for a client who has schizophrenia. The client states, "aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make? A. "Aliens do not exist." B. "Has your daughter had her baby?" C. "Do you mean to say a laboratory technician drew your blood last night?" D. "That does not sound real."

C The nurse should recognize that memory impairment is a cognitive symptom of schizophrenia. Other cognitive symptoms include impaired concentration, judgment, and problem solving. The nurse should recognize that feelings of hopelessness and other emotions are affective symptoms of schizophrenia. Paranoia is a positive symptom of schizophrenia. The inability to experience joy is a negative symptom of schizophrenia.

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms? A. "I just feel so hopeless." B. "The government has been watching my house." C. "I am unable to remember to brush my teeth." D. "No longer enjoy the activities I used to love."

A, C, D It is important to ask the client directly about the hallucinations and to focus on the client's feelings rather than agreeing with the client's hallucination. It is also important to assess for command hallucinations and the client's risk for injury to self or others.

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? Select all that apply A. "When did you start hearing these things?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices you are hearing telling you to hurt yourself?" E. "Why are the voices talking only you?"

A During a manic episode, the lithium blood levels should be 0.8 to 1.4. It is appropriate to administer the next dose as scheduled. Aminophylline can be prescribed for the treatment of severe toxicity of levels greater than 1.5. A lithium level of 1.2 is an expected finding for a client who is experiencing A manic episode. It is not necessary to repeat a stat repeat of the lab test.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. prior to administering the lithium carbonate, the client's lithium level is 1.2. Which of the following actions should the nurse take? A. Administer the next dose of lithium carbonate as scheduled. B. Prepare for the administration of aminophylline. C. Notify the provider for a possible increase in the dosage of lithium carbonate. D. Request a stat repeat of the client's lithium blood level.

B Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk of lithium toxicity.

A nurse is caring for a client who is prescribed lithium therapy The client tells of the plan to take ibuprofen for osteoarthritis pain relief period which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "The FMCG creases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."

B, D Observe for orthostatic hypotension and headache which is an adverse effect of phenazine

A nurse is caring for a client who is taking phenelzine. For which of the following manifestations should the nurse monitor as an adverse effect of this medication? SATA A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Hypomania E. Bruxism

A In preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles. Clients require oxygen administration until their respiratory status is stable.

A nurse is caring for a client who is undergoing electroconvulsive therapy to treat major depression. Following the procedure, which of the following actions should the nurse take? A. Administer oxygen B. Administer an anticonvulsant C. Administer an opioid antagonist D. Administer IV fluids

B The greatest risk to the client is self harm as a result of carrying out a suicide plan. The priority assessment is to determine how lethal the method is, how available the method is, and how detailed the plan is.

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority? A. Clients educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Clients insight into the reasons for the decision

A, C, D, E Olanzapine, Aripiprazole, Clozapine, and asenapine are available in orally disintegrating tablets, which is appropriate for clients who have difficulty swallowing oral tablets. This route also decreases the risk of agitation associated with an injection.

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to discuss the change to which of the following medications? SATA A. Olanzapine B. Quetiapine C. Aripiprazole D. Clozapine E. Asenapine

D The nurse should recognize associative looseness( speech that reveals thought patterns that shift rapidly from one topic to another) as a common finding for a client who has schizophrenia. Other findings include the presence of delusions, hallucinations, and altered speech patterns such as echolalia.

A nurse is collecting data from a client with schizophrenia who was recently admitted to acute care. Which of the following findings should the nurse expect? A. Seductive behaviors B. obsession with rituals C. uncontrolled appetite D. associative looseness

A, C, D, E Hallucinations, alterations in speech, delusions, and bizarre motor movements are all examples of positive symptoms.

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? Select all that Apply A. auditory hallucinations B. lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. flat affect

D the use of a no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies. A no-suicide contract is discouraged for clients who are in crisis, under the influence of substances, psychotic, very impulsive, and or very angry or agitated.

A nurse is conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat of suicide is attention-seeking behavior B. interventions are ineffective for clients who really want to commit suicide C. using the term suicide decreases the client's risk for suicide attempts D. no suicide contract decreases the client's risk of suicide

D elevated temperature is a manifestation of neuroleptic malignant syndrome that should be immediately reported to the provider. Other symptoms of the syndrome include rigidity, sweating, dysrhythmias, and fluctuations in blood pressure. Blurred vision And urinary hesitancy is an anticholinergic effect of fluphenazine, not an indication of neuroleptic malignant syndrome. Rigidity is an indication of NMS Not muscle flaccidity.

A nurse is monitoring a client who has schizophrenia and is receiving treatment with fluphenazine hydrochloride. Which of the following findings is an indication of neuroleptic malignant syndrome that the nurse should report to the provider? A. Blurred vision B. urinary retention C. muscle flaccidity D. elevated temperature

C clients taking quetiapine are at risk for abnormal glucose metabolism, which can result in diabetes myelitis. Therefore the client should have glucose testing periodically. Clients who take diuretics should have potassium testing periodically. Clients who have gout should have uric acid testing periodically. Clients who have hypocalcemia should have calcium testing periodically.

A nurse is providing teaching to a client has schizophrenia and is taking quetiapine fumarate. Which of the following blood tests should be performed periodically? A. Potassium B. uric acid C. glucose D. calcium

B Sedation is an adverse effect of amitriptyline during the first weeks of therapy. Foods with tyramine should be avoided if the client is prescribed an MAOI rather than a TCA like amitriptyline.

A nurse is providing teaching to a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to experience diarrhea while taking this medication." B. "May feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

B serotonin syndrome is a toxic effect that can occur from taking an MAOI such as tranylcypromine and an SSRI such as sertraline simultaneously. Manifestations include delirium, abdominal pain, muscle spasms, and irritability, and the condition can worsen to cause cardiovascular shock and death. The nurse should notify the provider immediately of this potential interaction.

A nurse is reviewing the medical record of a client who has a new prescription for tranylcypromine. The client still has a current prescription for sertraline. The nurse should notify the provider because taking these medications concurrently increases the risk of which of the following adverse effects? A. Increased intracranial pressure B. serotonin syndrome C. acute kidney injury D. hypertensive crisis

C The approach acid and lithium are both indicated for the treatment of bipolar disorder. The nurse may safely administer both of these medications to the client. Ibuprofen is not safe to administer to a client who is taking lithium because it can increase kidney absorption of lithium, which can lead to lithium toxicity. Haloperidol is not safe to administer to a client who is taking lithium because the combination increases the risk of extrapyramidal adverse effects and tardive dyskinesia. Hydrochlorothiazide is not safe to administer to a client who is taking lithium because it promotes sodium loss, which can lead to lithium toxicity.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. Which of the following medications may be administered safely while the client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

A, C, E voiding just before taking the medication will help minimize anticholinergic effects of urinary hesitancy or retention. Wearing sunglasses when outside will help minimize the anticholinergic effect of photophobia. Chewing sugarless gum will help minimize the anticholinergic effect of dry mouth.

A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? SATA A. Void just before taking the medication B. Increase the dietary intake of potassium C. Wear sunglasses when outside D. Change position slowly when getting up E. Chew sugarless gum

C Can take 6 to 8 weeks to achieve full therapeutic effectiveness of a tricyclic antidepressant. The nurse should instruct the client to take the tricyclic antidepressant each day at bedtime to decrease sleepiness during the day and they should instruct the client to avoid drinking any alcohol while taking tricyclic antidepressant because alcohol will block therapeutic effects of the medication.

A nurse is teaching a client who has a prescription for tricyclic antidepressant. Which of the following instructions should the nurse include in the teaching? A. "Take this medication within one hour of waking each morning." B. "Limit alcohol to two drinks per week while taking this medication." C. "It can take six weeks to achieve the full therapeutic effect of this medication." D. "Stop taking the medication if you experience dizziness."

C ECT is appropriate for the treatment of severe mania associated with bipolar disorder. It is prescribed for clients experiencing an acute episode rather then for preventing relapse.

A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

ANS: C The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to: a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

B, D Polyuria and muscle weakness is an early indications of lithium toxicity along with diarrhea, vomiting, fine hand tremors, slurred speech, and lethargy.

A nurses discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? SATA A. Constipation B. Polyuria C. Rash D. Muscle weakness E. Tinnitus

ANS: A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

ANS: D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.

A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

ANS: D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Nasal congestion c. Blurred vision d. Urinary retention

ANS: C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.

A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

ANS: C Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (non-therapeutic techniques). Saying "You must be feeling better today" is an assumption, which is non-therapeutic.

A patient diagnosed with major depression says, "No one cares about me anymore. I'm not worth anything." Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. "You look nice this morning." b. "I like the shirt you are wearing." c. "You're wearing a new shirt." d. "You must be feeling better today."

ANS: B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.

A patient diagnosed with major depression tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the patient to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

ANS: B Interventions should help the staff and patients come to terms with the loss and grow because of the incident. Then, a community meeting should occur to allow other patients to express their feelings and request help. Staff should be prepared to provide additional support and reassurance to patients and should seek opportunities for peer support. A sentinel event report can be prepared later. The other incorrect options will not control information or would result in unsafe care.

A patient hospitalized for 2 weeks committed suicide during the night. Which initial nursing measure will be most important regarding this event? a. Ask the information technology manager to verify the hospital information system is secure. b. Hold a staff meeting to express feelings and plan care for the other patients. c. Ask the patient's roommate not to discuss the event with other patients. d. Prepare a report of a sentinel event.

ANS: C Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy."

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of: a. dysthymia. b. euphoria. c. anhedonia. d. anergia.

ANS: A Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."