NUR 3065 - PrepU Chapter 19

The nurse is seeing a client at the local community mental health clinic. The client states, "I want to kill myself. I have nothing to live for; no one would miss me." What is the priority question the nurse should ask the client? "When do you plan to kill yourself?" "What about your family - don't you care about them?" "What has caused you to have such feelings?" "Do you have a specific plan for killing yourself?"

"Do you have a specific plan for killing yourself?" Explanation: A person with a specific plan and access to the means is considered to have very "lethal" suicidal ideation.

When assessing the client's ability to make sound judgments, what question should the nurse ask? "Do you eat breakfast?" "How many dimes are in one dollar?" "How do you plan to pay rent if you lose your job?" "Can you keep track of your finances on an ongoing basis?"

"How do you plan to pay rent if you lose your job?" Explanation: The nurse can usually assess judgment by noting the client's responses to family situations, jobs, use of money, and interpersonal conflicts. Asking if the client eats breakfast or can manage money are simple yes/no questions that are less likely to reveal data than asking for the client's plan of action in a hypothetical situation such as job loss. Asking how many dimes are in a dollar is a knowledge question.

Which factor would alert the nurse to the risk of suicide in the client? Select all that apply. Depression Rational though process Alcohol abuse Being married Lack of social support

Alcohol abuse Depression Lack of social support Explanation: Risk factors for suicide include irrational thought processes, depression, alcohol abuse, and lack of a spouse or social support.

The nurse suspects that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion? CAGE questionnaire GCS CAM SLUMS exam

CAGE questionnaire Explanation: The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. The St. Louis University Mental Status (SLUMS) exam assesses for cognitive impairment. The Glasgow Coma Scale (GCS) assesses a client's response to stimuli. The Confusion Assessment Method (CAM) is used to assess for confusion.

Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following? Coma Stupor Obtunded Lethargy

Coma Explanation: Coma reflects a client who is unresponsive to all stimuli, with the eyes remaining closed. Obtunded indicates that the client opens eyes to loud voice, responds slowly with confusion, and seems unaware of the environment. With stupor, the client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. With lethargy, the client opens eyes, answers questions, and falls back to sleep.

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population? Polyhedonia Comorbidity Death Bankruptcy

Death Explanation: Failure to diagnose depression can have fatal consequences-suicide rates among clients with major depression are eight times higher than in the general population.

An adult client who had a baby 2 weeks ago is brought to the ED because her boyfriend has noticed she has not been herself since they brought the baby home. The client's appearance is unkempt, her hair is a mess, and she appears not to have bathed for several days. What could these findings reflect? Need for more time to recover from childbirth Poor nutrition Depression Mania

Depression Explanation: Poor hygiene may be from paranoia of water, homelessness, severe depression, or incapacitation as a result of mental illness. Poor hygiene is not a result of mania, poor nutrition, or needing to recover from childbirth. The other options are distracters to the question.

Which clients are most at risk for depressive symptoms? (Select all that apply.) Females Married clients Chronically ill clients Males Divorced clients

Divorced clients Females Chronically ill clients Explanation: Watch carefully for depressive symptoms, especially in clients who are young, female, single, divorced or separated, seriously or chronically ill, or bereaved. Those with a prior history or family history of depression are also at risk.

The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first? Do you hear voices that tell you what to do? On a sense of 0 to 10, with 10 being most intense, how suicidal do you feel now? Do you have any thoughts of wanting to harm or kill yourself? Do you have a sense of hope for the future?

Do you have any thoughts of wanting to harm or kill yourself? Explanation: The priority is for the nurse would be to conduct a suicide assessment. The best question for the nurse to ask first is Do you have any thoughts of wanting to harm or kill yourself? The risk for suicide is not assessed using 0 to 10 scale. Asking about having a sense of hope for the future would be included in a spirituality assessment. The question, "Do you hear voices that tell you what to do?" assesses for auditory hallucinations.

When observing a client diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following? Dysphoric Euphoric Euthymic Labile

Euphoric Explanation: Terms used to describe mood include euthymic (normal), euphoric (elated), labile (changeable), and dysphoric (depressed, disquieted, restless).

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process? Derailment Incoherence Flight of ideas Circumstantiality

Flight of ideas Explanation: This represents flight of ideas, because the ideas are connected in some logical way. Derailment, or loosening of associations, has more disconnection within clauses. Circumstantiality is characterized by the client speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected. Incoherence lacks meaningful connection and often has odd grammar or word use.

A 32-year-old white woman comes to the clinic complaining of overwhelming sadness. She says for the past 2 months she has had crying episodes, difficulty sleeping, and problems with overeating. She says she used to go out with friends from work but now she just wants to go home and be alone. She also thinks that her work productivity has been dropping because she just is too tired to care or concentrate. She denies any feelings of guilt or suicidal ideation. She states that she has never felt this way in the past. She denies any recent illness or injuries. Past medical history consists of an appendectomy when she was a teenager; otherwise, she has been healthy. She is single and works as a clerk in a medical office. She denies tobacco, alcohol, or illegal drug use. Her mother has high blood pressure, and her father has a history of mental illness. Examination reveals a woman who appears her stated age and seems sad. Her facial expression does not change during conversation, and she makes little eye contact. She speaks so softly that the nurse cannot always understand her. Her thought processes and content seem unremarkable. What type of mood disorder is most consistent with these findings? Schizophrenia Major depressive episode Manic (bipolar) disorder Dysthymic disorder

Major depressive episode Explanation: Major depression occurs in a person with a previously normal state of mood. Symptoms often consist of a combination of sadness, decreased interest, sleeping problems (insomnia or hypersomnia), eating problems (decreased or increased appetite), feelings of guilt, decreased energy, decreased concentration, psychomotor changes (retardation or agitation), and preoccupation with thoughts of death or suicide. There must be five symptoms for a diagnosis of major depression. This client has all five: (1) sadness, (2) trouble sleeping, (3) overeating, (4) fatigue, (5) difficulty with concentration, and (6) no interest in doing things.

The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client? The client may be trying to anticipate the nurse's desired response. The client may be experiencing an early sign of delirium. The client is displaying a sign of early Alzheimer's disease. Slight delays in mental processing are normal in older adults.

Slight delays in mental processing are normal in older adults. Explanation: Slight delays in information processing are considered to be an age-related change and are not necessarily pathologic. There is no indication that the client may be trying to anticipate the nurse's desired response.

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing? Suicide plan Suicide means Suicide risk Suicide attempts

Suicide risk Explanation: Suicide risk is assessed by asking, "Do you have any thoughts of wanting to harm or kill yourself?" This question does not assess attempts at suicide, means of suicide, or plans of suicide.

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment? The client's fears about having a serious illness may be alleviated by the results of the exam. The exam provides data about mental health problems that the client may be afraid to report. The exam can provide clues about the validity of the client's responses now and throughout. The client will be less anxious, providing the nurse with more accurate and reliable data.

The exam can provide clues about the validity of the client's responses now and throughout. Explanation: Assessing mental status at the very beginning of the head-to-toe examination provides clues regarding the validity of the subjective information provided by the client during the history and throughout the exam. Thus, it is best to determine the validity of client responses before completing the entire physical exam only to learn that the client's answers to questions may have been inaccurate. Assessing mental status first will not necessarily lessen a client's anxiety or fears about a serious illness. The exam can provide data about mental health problems. However, this is not the primary reason for performing the exam at the very beginning.

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach? Validates the information the client provides during the rest of the assessment Is the easiest and shortest assessment to complete Requires little energy by the nurse to complete Ensures that this part of the assessment is completed before the client becomes fatigued

Validates the information the client provides during the rest of the assessment Explanation: Many assess mental status at the beginning of a head-to-toe assessment because it provides clues regarding the validity of the subjective information provided by the client throughout the examination. This assessment is not done first because it takes less energy for the nurse to complete it. This assessment can be quite lengthy. It is not done first because the client may become fatigued.

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status? Perceptions and thought processes Concentration and orientation Expressions and feelings Visual perceptual and constructional ability

Visual perceptual and constructional ability Explanation: Asking a client to draw the face of a clock tests the client's visual perceptual and constructional ability. Concentration is evaluated by noting the client's ability to focus and stay attentive. Orientation is tested by asking the client to state his or her name and the names of family members, time, day or season, and place. Thought processes and perceptions are evaluated by asking the client to say more about or verbalize his or her understanding of the current situation. Expressions and feelings are evaluated by asking the client how he or she is feeling and about plans for the future.

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client answered "no" to all of the four CAGE questions. answered "no" to three of the four CAGE questions. answered "yes" to one of the four CAGE questions. answered "yes" to three of the four CAGE questions.

answered "yes" to three of the four CAGE questions. Explanation: The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised.

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating? perseveration flight of ideas derailment confabulation

confabulation Explanation: Confabulation is the fabrication of facts or events in response to questions in order to fill in the gaps from impaired memory. Derailment is tangential speech with shifting topics that are loosely connected or unrelated. Perseveration is persistent repetition of words or ideas. Flight of ideas is an almost continuous flow of accelerated speech with abrupt changes from one topic to the next.

The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because depression and dementia are one in the same disorder. finding out why she is depressed will help determine the cause of her dementia. it is the most accurate tool to determine the stage of dementia. depression often mimics signs and symptoms of dementia.

depression often mimics signs and symptoms of dementia. Explanation: The Geriatric Depression Scale is used if depression is suspected in the older client. Read the questions to the client if the client cannot read.