NUR 162 prep u quiz 3
The nurse is caring for a client that states, "Everyone would be better off if I just drove off the bridge into the ocean!" Which question will the nurse ask to determine the intent to die?
"Can you tell me how serious you are about dying?" Explanation: Questions to ask when assessing a client's suicidal episode are placed into three categories: intent to die, severity of ideation, and degree of planning. When assessing the client's intent to die, appropriate questions are, "How seriously do you want to die?" and "How often do you have this thought?" and "Is this thought increasing in frequency?" because they help determine the severity of the ideation. "Have you done anything to put your plan into action?" is an example of a question to ask when assessing the degree of planning. Chapter 17: Mood Disorders and Suicide - Page 317
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?" Explanation: In the event of a suicide attempt, the nurse would assess the client's mood, affect, and behavior. Data regarding the attempted suicide and any previous attempts of self-destructive behavior would also be collected. Questions related to the client's actual intent and family history would not be part of a focused assessment. Chapter 17: Mood Disorders and Suicide - Page 318
A nursing instructor is teaching about different depressive disorders and identifies a need for further instruction when a student states what?
"Dysthymic disorder is less chronic than major depression." Explanation: Dysthymic disorder is milder but more chronic than major depression and is diagnosed when the depressed mood is present for most days for at least 2 years with two or more other symptoms present. Chapter 17: Mood Disorders and Suicide - Page 286
A 43-year-old female client is observed walking and dancing around the unit dressed in red high heels and a provocative style of dress. The client is seen sitting on the lap of a male client on the unit, and they are laughing. Which is the most therapeutic nursing intervention?
"I need for you to get off his lap, this behavior is not appropriate." Rationale: Clients have a long-standing pattern of excessive emotionality and attention-seeking behaviors. A matter-of-fact approach to limit-setting and boundaries effectively limits the manipulative and attention-seeking behaviors. Chapter 18: Personality Disorders - Page 344
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?
"The client sounds hypomanic. Let's schedule an appointment for this week for an evaluation. The client may need additional or different medication." Explanation: Hypomania is a slightly less severe subcategory of mania. Differentiating points are that hypomania has no psychotic features and does not impair functioning to a level that necessitates hospitalization. Most hypomanic episodes in bipolar II disorder occur immediately before or after a major depressive episode. Chapter 17: Mood Disorders and Suicide - Page 285
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 a nurse would be most important to ask at this time?
"What have you had to eat or drink today?" Explanation: The client is exhibiting signs of a hypertensive crisis, which can occur when a client is receiving MAOI therapy (selegiline) and ingests food or other substances that contain tyramine. Thus, the nurse should ask the client what the client has had to eat or drink. Drug levels are used to monitor tricyclic antidepressants. Asking about chest pain would be appropriate after obtaining information related to what the client has ingested. Herbal remedies can interact with medications, but this information would be obtained after determining whether the client has ingested foods and fluids containing tyramine. Chapter 17: Mood Disorders and Suicide - Page 292
A client is admitted for acute pancreatitis due to chronic alcohol use disorder and has not had a drink in 2 days. The client states, "bugs are crawling on the bed!" The client is anxious, agitated, diaphoretic. Which is the priority action by the nurse to treat the withdrawal symptoms?
Administer chlordiazepoxide. Explanation: Because alcohol withdrawal can be life-threatening, detoxification needs to be accomplished under medical supervision. Safe withdrawal is usually accomplished with the administration of benzodiazepines such as lorazepam, chlordiazepoxide, or diazepam to suppress the withdrawal symptoms. Sedation allows for safe withdrawal from alcohol and causes drowsiness and reduces anxiety, which is the intended purpose. Benzodiazepines are the drugs of choice in most regions because of their high therapeutic safety index and anticonvulsant properties. Monoamine oxidase inhibitors (antidepressants) can cause death when combined with alcohol. MAOIs should not be taken with alcohol, or cough, cold, flu, or hay fever medicine. Phenothiazines should not be used in people who are intoxicated with alcohol or other drugs that cause drowsiness/slowed breathing. Narcotics also cause slowed respirations, which coupled with the alcohol can cause respiratory arrest. Chapter 19: Addiction - Page 367
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 selective serotonin reuptake inhibitor (SSRI) Cognitive therapy Explanation: For most clients with a new diagnosis of depression, medication is combined with cognitive and behavioral interventions. Usually an SSRI is tried first. MAOIs are reserved for clients unresponsive to other antidepressants, and rTMS is used for depression unresponsive to conventional treatment. Phototherapy is used specifically for seasonal depression. Chapter 17: Mood Disorders and Suicide - Page 294 - 295
The nurse is caring for a psychiatric-mental health client who has just been diagnosed with bipolar disorder. The physician has ordered medication for for the client. Which class of medications, if prescribed, would the nurse question?
Antidepressants Explanation: Mood stabilizers are the primary drugs used for bipolar disorders. They include lithium, anticonvulsants, and atypical antipsychotics (often combined with lithium or anticonvulsants). The American Psychological Association guideline (2002) recommends discontinuation of antidepressants as soon as possible in clients with bipolar disorders because these drugs may induce a switch to mania. Chapter 17: Mood Disorders and Suicide - Page 307
Which diagnosis is associated with a pervasive disregard for and violation of the rights of others?
Antisocial personality Explanation: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others. Antisocial personality disorder is a common diagnosis for those in prison and jails. Chapter 18: Personality Disorders - Page 336
A mental health nurse is planning a psychotherapy group for clients with personality disorders. The nurse knows the group will be comprised of a significant number of clients from Arab and Asian ethnicity. Which should the nurse consider when planning this group?
Be aware of the how each client's personality has been affected by his or her cultures values and beliefs. Explanation: The mental health nurse whose client population has substantial number of clients of Asian and Arab ethnicity with personality disorders can ensure effective nursing care best by being aware of the how each client's personality has been affected by his or her culture's values and beliefs. Chapter 18: Personality Disorders - Page 332
A nurse is developing a plan of care for a client diagnosed with an antisocial personality disorder who has been admitted to the inpatient psychiatric unit. Which item(s) would the nurse most likely include? Select all that apply.
Developing a therapeutic relationship Holding the client responsible for behavior Explanation: The nurse should develop a therapeutic relationship, although it may be difficult because individuals do not attach to others. The nurse should hold the client responsible for behavior, avoid arguing or bargaining about unit rules, encourage the client to recognize and discuss thoughts, and use a direct approach to teaching. Using a lecture-like approach can lead to resentment by the client. Chapter 18: Personality Disorders - Page 338
The nurse provides care to a client who is experiencing side effects due to prescribed antidepressant medication. Which nonpharmacologic intervention does the nurse include in the plan of care for the client who is experiencing dry mouth? Select all that apply.
Drink 6 to 8 cup of water per day. Use sugarless gum and/or lozenges. Explanation: Nonpharmacologic interventions to treat dry mouth, caries, and inflammation of the mouth include the use of sugarless gum or lozenges, increasing the intake of water to at least 6 to 8 cups per day, and using a toothpaste that is specific for dry mouth. If these interventions are ineffective, pharmacologic interventions can be implemented including bethanechol and pilocarpine drops. Exercising daily is an intervention for the client who experiences weight gain due to pharmacologic antidepressant therapy. Changing positions slowly is a nonpharmacologic intervention for the client who experience orthostatic hypotension, not dry mouth. Increasing the consumption of fresh fruits and vegetables is an appropriate intervention for the client experiencing constipation, not dry mouth. Chapter 17: Mood Disorders and Suicide - Page 290
A client with borderline personality disorder is prescribed pharmacotherapy. The nurse understands that this treatment aims to control which of the following? Select all that apply.
Emotional dysregulation Impulsive aggression Cognitive disturbances Anxiety Explanation: Pharmacology is used to control emotional dysregulation, impulsive aggression, cognitive disturbances, impulsive aggression, cognitive disturbances, and anxiety as an adjunct to psychotherapy. Chapter 18: Personality Disorders - Page 332
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 Explanation: The behaviorists hold that depression occurs primarily as the result of a severe reduction in rewarding activities or an increase in unpleasant events in one's life. The cognitive approach maintains that irrational beliefs and negative distortions of thought about the self, the environment, and the future engender and perpetuate depressive effects. Family theorists ascribe maladaptive patterns of family interaction as contributing to the onset of depression. Psychodynamic theorists ascribes the etiology to an early lack of love, care, warmth, and protection. Chapter 17: Mood Disorders and Suicide - Page 310
Gambling, binge eating, and engaging in unsafe sex are examples of what?
Impulsivity Rationale: Impulsivity occurs in people who have difficulty delaying gratification or thinking through the consequences before acting on their feelings. Examples of impulsivity are gambling, spending money irresponsibly, binge eating, engaging in unsafe sex, and abusing substances. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed. Dissociation occurs when thinking, feeling, or behaviors occur outside a person's awareness. Chapter 18: Personality Disorders - Page 331
The nurse is caring for a client with a history of a substance use disorder. Which problem(s) will the nurse add to the plan of care when the client reports difficulty adjusting without the substance? Select all that apply.
Ineffective coping inability to fulfill role expectations Explanation: A client recovering from substance use will need ongoing treatment and support. Problems commonly identified when caring for a client with a substance use disorder include ineffective coping and inability to fulfill role expectations. Ineffective rehabilitation, difficulty with communication, and fear of developing physical symptoms are not appropriate problems for a client having difficulty adjusting after recovering from substance use. Chapter 19: Addiction - Page 374
An older adult client with liver disease is experiencing alcohol withdrawal. Based on the nurse's understanding of drug therapy, which of the following would the nurse expect to be prescribed?
Lorazepam Explanation: Antianxiety and sedating drugs, such as benzodiazepines, are titrated downwardly over several days as a substitution for the alcohol. Chlordiazepoxide (Librium) and diazepam (Valium) have longer half-lives and smoother tapers. Lorazepam (Ativan) is better for the older adult and people with liver impairment. Fluoxetine is not used. Chapter 19: Addiction - Page 360
A client is brought to the emergency department by a friend with reports of confusion and vomiting after using cocaine. The heart rate is 146 beats per minute, BP 200/140 mm Hg, and pupils are dilated. Which is the necessary action(s) by the nurse? Select all that apply.
Maintain a safe environment for the client. Monitor heart rate and blood pressure frequently. Explanation: There is no antidote for cocaine intoxication. Naloxone is used for an opioid overdose and haloperidol is used for the control of psychosis with the use of halucinogenic agents such as LSD. The nurse must carefully monitor the heart rate and blood pressure frequently to prevent complications related to the effects of the cocaine. Safety is a high priority intervention, especially due to the client's confusion. Chapter 19: Addiction - Page 363
A nurse is assessing a client with borderline personality disorder. Which response pattern would the nurse most likely assess? Select all that apply.
Mood lability Anger issues Impulsive behavior Fear of abandonment Explanation: Response patterns of persons with BPD include mood lability, problems with anger, impulsive behavior, and fear of abandonment. Clients with BPD often exhibit paranoid ideation, not suicide ideation. Chapter 18: Personality Disorders.
A client with bipolar disorder is experiencing a major depressive episode. Which would the nurse expect to assess? Select all that apply.
Obsessive rumination Hypersomnia Difficulty concentrating Explanation: During a major depressive episode, a client would exhibit obsessive rumination, insomnia or hypersomnia, diminished ability to concentrate, or indecisiveness. Flight of ideas and engaging in widespread shopping sprees would characterize mania. Chapter 17: Mood Disorders and Suicide - Page 285
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 Explanation: In rapid cycling, clients have four or more manic episodes for at least 2 weeks in a single year. The episodes are marked by either partial or full remission for at least 2 months or a switch to an episode of opposite type. Chapter 17: Mood Disorders and Suicide - Page 287
When assessing a client with borderline personality disorder (BPD), which behaviors would the nurse expect to find? Select all that apply.
Repeated, frequent crisis episodes Self-directed anger Learned helplessness Deceptive competence Explanation: Behavior patterns associated with BPD include: emotional vulnerability (high sensitivity to negative emotional stimuli), self-invalidation (self-directed anger and no personal awareness), active passivity (learned helplessness), unrelenting crises (repeated, stressful, negative environmental events/roadblocks), inhibited grieving, and apparent competence (appearing more competent than person actually is). Chapter 18: Personality Disorders - Page 338
A client in the emergency department has self-inflicted wounds on both arms. Assessment reveals that the client was diagnosed with borderline personality disorder 6 months ago, for which the client has been receiving outpatient treatment. The client tells the nurse that the client recently found out the client's therapist is moving and will no longer be able to work with the client. What is the priority nursing diagnosis for this client?
Self-mutilation Rationale: Although all the above are problems for this client, the highest priority nursing diagnosis is self-mutilation. If left untreated, self-mutilation can lead to suicide attempts. Chapter 18: Personality Disorders - Page 341
When developing the plan of care for a client with borderline personality disorder (BPD), which areas would the nurse identify as likely problematic? Select all that apply.
Sleep Nutrition Self-harm Explanation: Usually, clients with BPD are managing hydration, self-care, and pain well. Problem areas include sleep, nutrition, and self-harm. Chapter 18: Personality Disorders - Page 346 - 347
For clients with borderline personality disorder, there is a tendency to see the world as either good or bad. As a result, these clients use the primitive defense of what?
Splitting Rationale: Because borderline personality disorder clients view the world in absolutes, nurses and other treatment team members are alternatively categorized as all good or all bad. The primitive defense is termed splitting and presents clinicians with a challenge to work openly with each other, as well as the client, until the issue can be resolved through team meetings and clinical supervision. Regression, denial, and compensation are ego defense mechanisms. Chapter 18: Personality Disorders - Page 342
A nurse is preparing an educational session for family members affected by substance abuse. Which point should the nurse include in the session? Select all that apply.
Substance abuse is an illness like any other. An individual with substance abuse issues typically cannot use drugs socially. Explanation: When providing family education about substance abuse, it is important for the nurse to ensure that families understand substance abuse is an illness like any other. Families should also be aware that it is not possible for people with substance abuse issues to use drugs socially, there is no minimal amount that can be used without the potential for relapse. Feedback from families about relapse signs, for example, a return to previous maladaptive coping mechanism, is vital Chapter 19: Addiction - Page 374
The nurse is involved in the care of a client with antisocial personality disorder. Which purpose does the nurse identify as a priority when participating in a periodic team meeting when caring for this client?
Team consistency is important to prevent manipulation by the client. Explanation: It is important to be consistent and firm with the care plan and not to make independent changes in rules or consequences. Any change should be made by the staff as a group and conveyed to all staff members working with this client. Consistency is essential and may require team dialogue. If the client can find just one person to make independent changes, any plan will become ineffective. Care providers must be kept up to date on the components of the client's treatment plan, but this can be accomplished without meetings. Similarly, updates can be communicated or documented in different ways. Staff's frustrations must be dealt with appropriately, but the primary focus for all treatment planning should be centered on meeting the client's needs. Chapter 18: Personality Disorders - Page 338
A client is hospitalized on a psychiatric unit secondary to a suicide attempt. The client has been diagnosed with depression and is consistently depressed. When assessing the client, which finding would alert the nurse that the client's suicidal risk has increased?
The client says the client feels better, with more energy to interact with others Explanation: During the depths of depression, clients may not have the energy to complete a suicide. As clients begin to feel better and have increased energy, they may be at a greater risk for suicide. If a previously depressed client appears to become energized overnight, he or she may have made a decision to commit suicide and thus may be relieved that the decision is finally made. The nurse may misinterpret the mood improvement as a positive move toward recovery; however, this client may be very intent on suicide. These individuals should be carefully monitored to maintain their safety. Chapter 17: Mood Disorders and Suicide - Page 317
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 too tired to answer all of the nurse's questions in one session. Explanation: Clients with depression may have low energy levels which makes them unable to answer questions during assessment. Thus, a complete assessment is rarely accomplished in one session for such clients. A complete assessment may be obtained in approximately three to four sessions with the client. It is unlikely that the client would be voluntarily uncooperative to the nurse. Unlike clients with cognitive and other psychotic disorders, this client most likely does not have a reduced attention span that would interfere with the ability to understand and answer the nurse's questions. Cognition is not usually impaired in clients with depression. Chapter 17: Mood Disorders and Suicide - Page 298
The nurse is providing care for a client who has been diagnosed with antisocial personality disorder. Which outcome should the nurse prioritize when planning this client's care?
The client will to express anger in an adaptive, nonviolent manner Explanation: Persons with antisocial personality disorder lack the impulse control to refrain from acts that provide them with immediate gratification. Aggressive behavior is often a problem for these individuals and their family members. Similar to patients with borderline personality disorder (BPD), people with ASPD tend to be impulsive. Instead of self-injury, these individuals are more likely to strike out at those who are perceived to be interfering with their immediate gratification. Anger control assistance (helping to express anger in an adaptive, nonviolent manner) becomes a priority intervention. Such individuals are unlikely to become overly dependent on other people or systems. The need to control impulses and anger supersedes the need to normalize sleep, rest, and activity. Chapter 18: Personality Disorders - Page 331
Which statement about clients with a dual diagnosis is accurate?
Traditional methods of treatment have not been very successful for these clients. Explanation: Traditional methods of treatment for major psychiatric disorders and substance dependency (i.e., substance dependency programs) have not been successful in treating clients with dual diagnoses. Chapter 19: Addiction - Page 369
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. Push fluids. Contact the physician. Explanation: If symptoms of moderate to severe toxicity to lithium are noted, the nurse should withhold the medication, obtain a blood sample to analyze the lithium level, push fluids, and contact the physician for further instructions. Chapter 17: Mood Disorders and Suicide - Page 315
The nurse is preparing a plan of care for a 30 year-old female client in the manic phase of bipolar disorder.
appropriate: - Limit interaction time. - Monitor lithium blood level - Reduce stimuli before bedtime. - Provide meals with finger foods. - Use a calm, nonthreatening approach. Inappropriate - Provide a schedule of activities. - Coach on deep-breathing exercises. - Encourage to attend group therapy. Chapter 25: Next Generation - NGN - Page 312-313
A 48-year-old male client is transported for emergency care with symptoms of an overdose from an unknown substance.
cocaine -Respiratory depression - Seizures -Cardiac arrest -Chest pain -Psychosis alcohol - resp depression - seizures - cardiac arrest PCP - resp depression - seizures - psychosis - vomiting - confusion Chapter 25: Next Generation - NGN - Page 360-365
A client with a history of alcohol use disorder seeks medical attention for withdrawal symptoms. Which medication(s) would the nurse expect to be prescribed to help reduce the symptoms? Select all that apply.
diazepam lorazepam chlordiazepoxide Explanation: Because alcohol withdrawal can be life threatening, detoxification needs to be accomplished under medical supervision. Safe withdrawal is usually accomplished with the administration of benzodiazepines such as diazepam, lorazepam, or chlordiazepoxide to suppress the withdrawal symptoms. Withdrawal can be accomplished by fixed-schedule dosing known as tapering, or symptom-triggered dosing in which the presence and severity of withdrawal symptoms determine the amount of medication needed and the frequency of administration. Furosemide is a diuretic and acetaminophen is an analgesic, neither of which are used to reduce the symptoms of alcohol withdrawal. Chapter 19: Addiction - Page 360
A client recovering from a substance use disorder reports feelings of anxiety. Which activity(ies) would the nurse recommend to help relieve the client's stress? Select all that apply.
relaxing exercise listen to music learn a new activity Explanation: The nurse can help a client find ways to relieve stress or anxiety that does not involve the use of the substance. These suggestions include teaching relaxation, exercising listening to music, or learning a new activity. The client should not be encouraged to meet up with old friends, particularly if socializing with the friends involves the use of the substance. Chapter 19: Addiction - Page 375
An older client who has attempted suicide has an underlying diagnosis of depression. Which would a nurse anticipate as being ordered for the client?
selective serotonin reuptake inhibitor electroconvulsive therapy Explanation: Medication management focuses on treating the underlying psychiatric disorder. For depression, a nonlethal antidepressant (e.g., selective serotonin reuptake inhibitor) usually will be prescribed. For clients with schizophrenia and schizoaffective disorder, antipsychotics may be used; however, only clozapine, an atypical antipsychotic, has been shown to be effective. Electroconvulsive therapy (ECT) has been used in both inpatient and outpatient settings to alleviate severe depression, especially in medically compromised groups, such as older adults, who may not tolerate conventional pharmacotherapy for depression. Chapter 17: Mood Disorders and Suicide - Page 288-290
During a home visit, a 47-year-old female client with depression who is taking time off from work because of being recently widowed admits not taking medication after learning that two other close family members died in an automobile accident.
suicide lack of support system not taking medication Explanation: Suicidal behavior is the occurrence of persistent thought patterns and actions that indicate a person is thinking about, planning, or enacting suicide. Clients with major depressive disorder are at increased risk for suicide. There are risk factors for which the nurse should assess the client. The possibility of suicide should always be a priority with clients who are depressed. Assessment and documentation of suicide risk should always be included in client care. The lack of support systems is identified as a risk factor for suicide in the client with depression. The client is a recent widow and just learned that two other close family members died. The client's support system is shrinking. Women often use pills or other poisonous substances to commit suicide. The client reports not taking medication since learning of the other family members' deaths. The client could be stockpiling the medication and use this as a suicide plan. Clients who are depressed may withdraw and miss appointments. This might be an issue for the client in the future but there is no evidence that it is an immediate concern. Even though inadequate self-care is a symptom of depression, there is no evidence that the client is not performing self-care activities. The client with depression will be fatigued and lack interest in activities. It is unlikely that the client would be concerned about work obligations because of taking time off. It is unknown how the client will be needed or participate in the funerals for the recently deceased family members. Even though lack of financial stability can impact health behaviors and the ability to cope in conjunction with the losses the client has experienced, the client is employed and is just taking time off because of the death of the spo
A client who routinely uses methamphetamine is withdrawing from the substance. Which finding indicates to the nurse that the client is crashing?
suicide ideation Explanation: Withdrawal from stimulants occurs within a few hours to several days after cessation of the drug and is not life threatening. Marked withdrawal symptoms are referred to as "crashing"; the person may experience depressive symptoms, including suicidal ideation, for several days. Flight of ideas, aggressiveness, and acute confusion are not symptoms of crashing from methamphetamine use. Chapter 19: Addiction - Page 363
