Passpoint - Mood, Adjustment, and Dementia Disorders

A client taking metronidazole asks the nurse if it is okay to drink alcohol while taking this medication. What is the nurse's best response?

"Abstain from alcohol while on the drug."

A client is admitted to the behavioral health unit with severe depression. The nurse suspects that the client is at risk for suicide. Which question would be most appropriate for the nurse to ask while collecting data about the risk for suicide?

"Are you having thoughts about hurting yourself?"

A nurse is caring for a client diagnosed with bipolar disorder who is taking lithium carbonate. When reviewing information about this therapy, what instruction would be most important to reinforce with this client?

"Be sure to drink at least 2 ½ quarts [2500 mL] a day."

A hospitalized client who cares for a parent with Alzheimer's disease at home reports feeling guilty because, at times, the client wishes the parent would die. When talking with the client, which response would be most appropriate?

"Being responsible for your father's care must be difficult."

A geriatric client with Alzheimer's disease has been living with his grown child's family for the last 6 months. He wanders at night and needs help with activities of daily living. Which statement by his child suggests that the family is successfully adjusting to this living arrangement?

"Dad has presented many challenges. We have alarms on all the outside doors now. Respite care gives us a break."

A nurse is caring for a client who states, "I can't keep living like this. I just want to end it all." What is the nurse's best response?

"Do you plan to harm yourself?"

The nurse is obtaining data about the early life of a client with borderline personality disorder (BPD). Which statement made by the client would correlate with this diagnosis?

"I had a violent, chaotic family life."

A client on the behavioral health unit is being evaluated for depression. When gathering data, which client statement would lead the nurse to suspect depression?

"I just know my daughter doesn't love me anymore."

A nurse is working with a client diagnosed with bordeline personality disorder with recurrent suicidal thoughts. Which client statement does the nurse relate to the client's diagnosis of borderline personality disorder?

"I might as well check out because my boyfriend doesn't want me anymore."

The daughter of a client diagnosed with Alzheimer's disease tells a nurse, "My mother is incompetent. You'll need to contact me or my sister if any decision must be made about my mother's care." Which response by the nurse is best?

"I must respect your mother's rights until she is legally deemed incompetent.

A nurse is caring for a client who threatens suicide and is placed on constant observation. The nurse follows the client into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which response by the nurse is most appropriate?

"I must stay with you until we are sure you will not hurt yourself."

A client with antisocial personality disorder says, "I always want to blow things off." Which response by the nurse is most appropriate?

"Let's work on considering some options and strategies."

A client who lost her spouse suddenly 30 years ago tells a nurse during an interview, "My husband's shoes are at the side of the bed where he left them." The client's daughter informs the nurse that her mother constantly speaks about her deceased husband. Which statement by the daughter shows an understanding of maladaptive grief?

"My mother is in a prolonged phase of the grief process."

A nurse isobserving the effectiveness of an assertiveness group attended by a client with dependent personality disorder. Which client statement indicates the group had therapeutic value?

"I want to talk about something that's bothering me."

The nurse is reinforcing education provided for the client and spouse regarding electroconvulsive therapy (ECT). What statement made by the client would indicate that further education is required?

"I will have no further episodes of depression after I have the procedure."

A client who has been taking imipramine, 125 mg P.O. daily, for 1 week wants to stop taking the medication because the client still feels depressed. Which response by the nurse would be most appropriate at this time?

"Imipramine must build up to a therapeutic level; it may take 3 to 4 weeks to reduce depression."

A client avoids leaving home to shop for groceries and states to the nurse, "I feel crazy from the fear even when I know it is unrealistic." What is the best response by the nurse?

"It is better if you gradually face your fear with professional coaching."

During the admission data collection, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, "Do you think I will ever get better? I don't know what is wrong with me." The nurse's most supportive response would be:

"It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal."

A client diagnosed with major depression has started taking amitriptyline hydrochloride. The nurse is reviewing the instructions about this drug and potential adverse effects. The nurse determines that the client has a good understanding of the drug therapy based on which client statement?

"It's not unusual for this drug to make my mouth feel a bit dry."

A client admitted to the behavioral health unit diagnosed with antisocial personality disorder has made all of the telephone calls permitted for the day. The client asks the nurse, "Can't I just make one more phone call?" Which response by the nurse would be best?

"No, you can't. You have used all of your allotted phone calls."

The nurse is discussing the incidence of obsessive-compulsive disorder (OCD) with a client. Which statement made by the client demonstrates an understanding of the education?

"OCD is as common as diabetes and asthma."

Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective?

"Sometimes I can see what causes relationship problems."

The spouse of a client diagnosed with vascular dementia asks the nurse if this is the same as having Alzheimer's disease (AD). Which response by the nurse is most appropriate?

"There are similarities in the conditions but they are not the same condition."

A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The client's wife states that he was diagnosed with Alzheimer's disease 3 years ago and has had increasing memory loss. She tells the nurse she is worried about how she'll continue to care for him. Which response by the nurse would be most helpful?

"What aspect of caring for your husband is causing you the greatest concern?"

A client is brought to the emergency department by his spouse, who reports the client has become increasingly confused over a period of 3 to 4 days. When questioned, the spouse reports there has never been a history of confusion before. Which initial question by the nurse is most appropriate?

"What medications and supplements are being taken?"

A parent of a child with autism asks the nurse, "Will my child ever get better?" Which is the best response by the nurse?

"With behavioral therapy, your child's symptoms may get better."

One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic?

"You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy.

An older adult client is prescribed fluoxetine, 40 mg by mouth twice per day, for treatment of depression. The client has difficulty swallowing, so the pharmacy dispenses the oral solution containing 20 mg/5 mL. How many milliliters of solution should the nurse administer to achieve the prescribed dose? Record your answer using a whole number.

10

The nurse is caring for a client who has been diagnosed with delirium. Which of the following is characteristic of delirium?

Acute onset and lasts hours to a number of days

A nurse is caring for an older adult client who exhibits signs of dementia. When assisting with the development of the client's plan of care, the nurse incorporates understanding that which condition is the most common cause of dementia?

Alzheimer's disease

A client with gradually occurring global impairments of cognitive functioning, memory, and personality is most likely to have:

Alzheimer's-type dementia.

Which foods are contraindicated for a client taking tranylcypromine?

Chicken livers, Chianti wine, and beer

A client with self-inflected wrist lacerations was stabilized in the emergency department and then transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. After initiating antidepressant therapy, the client is now exhibiting an increase in energy levels. What nursing intervention is most appropriate?

Continue suicide precautions.

A client who retired six weeks ago, has been diagnosed with an adjustment disorder with mixed anxiety and depression. What can the nurse reinforce to help the client adapt well to the stress? Select all that apply.

Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity.

Discharge instructions for clients receiving tricyclic antidepressants include which of following information?

Don't consume alcohol.

A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would best prevent further regression in the client's personal hygiene?

Encouraging the client to perform as much self-care as possible

A client with major depression frequently is irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach?

Firmness

Which nursing action is most appropriate when trying to diffuse a client's impending violent behavior?

Helping the client identify and express feelings of anxiety and anger

The nurse is caring for a client diagnosed with borderline personality disorder. The nurse tells the client that they will be meeting for 1 hour every week on Monday at 1 p.m. Which statement best describes the rationale for setting limits for a client with borderline personality disorder?

It helps the client clarify limits.

A client who was attempting to carry out a suicide plan is admitted to the unit. Which nursing intervention is the highest priority for this client?

Making sure that a health care team member stays with the client

A client has been prescribed donepezil. What teaching reinforcement should the nurse add to a discharge plan of care? Select all that apply.

May cause fainting or dizziness. Administer the medication on a regular schedule.

The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client?

use short, simple commands when providing instruction

The nurse is preparing a teaching plan for an elderly client with depression who will continue on a prescription for venlafaxine after discharge. Because of age-related cognitive changes the nurse should use which approach to client teaching?

Repeat new information frequently.

After an upsetting divorce, a client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client?

Risk for self-directed violence related to plans to commit suicide by handgun

A nurse is assigned to care for a client recently admitted to the psychiatric facility who has attempted suicide. When collecting data from the client, which action would be most appropriate at this time?

Search the client's belongings carefully for items that could be used to attempt suicide.

A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?

Set limits, with clear and consistent consequences, for behavior.

A client has been prescribed venlafaxine extended-release capsules by mouth, once daily, for major depression following a stroke. The client has difficulty swallowing pills since the stroke. How should the nurse intervene?

Sprinkle the contents of the capsule over applesauce and administer it to the client.

While the nurse is collecting data on a client with depressive symptoms, the client reports taking an herbal medication to help with symptoms. When the nurse questions the client further, which herbal therapy would the client most likely report using?

St. John's wort

A client is diagnosed with somatic symptom disorder. What understanding should the nurse have regarding somatic symptom disorder when rendering care to this client?

Symptoms are real to the client, even though there may not be an organic etiology.

The nurse is gathering data from a client suspected of early dementia. Which finding shows impairment in abstract thinking and reasoning?

The client can't find similarities and differences between related words or objects.

A client received treatment for depression for the past three weeks. The nurse determines that the treatment is effective based on observation of which behavior?

The client talks about the difficulties of returning to college after discharge.

A client with paranoid personality disorder responds aggressively to something another client said during a psychoeducational group session. Which rationale explains the likely underlying cause of the client's response to the interaction?

The client took the statement as a personal criticism.

Which long-term goal is appropriate for a client with paranoid personality disorder who is trying to improve peer relationships?

The client will become involved in activities that foster social relationships.

A client has been diagnosed with a conversion disorder after presenting with new onset paralysis in a lower extremity. When providing education about this phenomena to a group of nurses, what information should be included? Select all that apply.

The onset of these symptoms may be attributed to psychological stressors. Most symptoms will resolve.

The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which trait would the nurse be likely to uncover during data collection?

a low tolerance for frustration

A client who has just had electroconvulsive therapy (ECT) asks for a drink of water. Which intervention would be the nurse's priority?

assess the gag reflex

A client arrives at a mental health clinic stating, "I feel numb and empty most of the time. I don't have any energy to do what I normally do." Further investigation reveals that the client has experienced these difficulties since the death of a best friend 6 months ago. Which response by the nurse would be best?

advise the client that it is not unusual for grieving and loss to continue for quite some time

The nurse observes a child with autism banging his or her head against the floor repetitively. Which nursing action is the priority?

apply a helmet on the child

The nurse is assisting with the development of a treatment plan for a client with a specific phobia. Which intervention should the nurse prepare the client for?

behavioral therapy

Which intervention can the nurse discuss with the parents of a child with attention deficit hyperactivity disorder (ADHD) to help their child to achieve daily tasks?

break up the task into smaller steps

The nurse is obtaining data from a group of clients with depression. Which clients would the nurse recognize would most benefit from electroconvulsive therapy (ECT)?

clients who are severely depressed and do not respond to medication trials

The nurse is providing care to a client with Alzheimer's disease (AD). Which nursing intervention takes priority?

control the environment by providing structure, boundaries, and safety

The nurse is caring for a client with a cognitive disorder. Which characteristic does the nurse observe that correlates with a cognitive disorder?

deficit in memory

The nurse is collecting data for a client diagnosed with a dementia disorder. Which factor is most important for the nurse to determine when collecting data for this diagnosis?

degree of impairment

A nurse is caring for a client diagnosed with borderline personality disorder. Which condition is most likely to coexist with the client?

depression

A client with major depression begins to improve and participates in treatment programs on the unit. Which client behavior would best indicate to the team that the client is ready for discharge?

discusses plans to return home and continue outpatient treatment

The nurse is obtaining data when the postpartum client comes for follow-up visits at 2, 4, and 6 weeks. When would be the best time for the client to have postpartum depression screenings?

during each of the three visits using the Edinburgh Postnatal Depression Scale

A client reports feelings of hopelessness, depression, poor appetite, insomnia, low self-esteem, and difficulty making decisions. The client tells the nurse that these symptoms began at least two years ago and have been ongoing. The nurse recognizes that the client's signs and symptoms are consistent with which disorder?

dysthymic disorder

Which short-term goal is appropriate for a client with an antisocial personality disorder who acts out when distressed?

educating the client about expressing feelings in a nondestructive manner

A client exhibits signs of dementia. Which condition, that can cause a dementia similar to Alzheimer's disease (AD), is reversible?

electrolyte imbalance

A client is admitted to a long-term-care facility with a diagnosis of organic mental disorder. The client has been wearing the same undergarments for several days. Which nursing intervention would best prevent further regression in the client's personal hygiene habits?

encourage the client to perform as much self-care as possible

A client with a diagnosis of borderline personality disorder is admitted to the unit after slashing their wrist. When assisting with the planning of care, which goal is most appropriate for this client?

establish a therapeutic relationship with the client

Which short-term goal is appropriate for a client with borderline personality disorder who displays low self-esteem?

express fears and feelings

A nurse is working with a client diagnosed with antisocial personality disorder. Which nursing intervention is most appropriate for the client who acts out when distressed?

expressing feelings in a nondestructive manner

Which communication guideline should the nurse use when talking with a client experiencing mania?

focus and redirect the conversation as necessary

Which nursing intervention would help a client with a borderline personality disorder identify appropriate behaviors?

formulate a behavioral contract

The nurse is assigned to care for a client with early-stage Alzheimer's disease (AD). Which nursing interventions should be included in the client's care plan? Select all that apply.

furnish the client's environment with familiar possessions assist the client with activities of daily living (ADLs) as necessary assign tasks in simple steps

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on time spent in bed during the day.

A home health care nurse is working with the family of a client who has Alzheimer's disease. The client's spouse is too exhausted to continue providing care alone and the client's adult children live too far away to provide relief on a weekly basis. Which nursing intervention would be most helpful?

investigate community resources for adult day care and other services

The nurse finds a client with Alzheimer's disease wandering in the hall at 3 a.m. The client has removed all clothing and says to the nurse, "I'm just taking a stroll through the park." What is the priority action by the nurse?

immediately help the client back to his or her room and into some clothing

A client is diagnosed with dependent personality disorder. When gather data from the client, which behavior would the nurse suspect as being most likely indicative of ineffective coping?

inability to make choices and decisions without advice

A client is prescribed lithium to treat bipolar disorder. Which should the nurse include when developing a teaching plan for this client? Select all that apply.

increase fluid intake to 2.5 to 3 L daily maintain adequate sodium intake daily take acetaminophen for a headache; avoid NSAIDs like ibuprofen expect to have blood levels monitored every 1 to 3 months

Parents of a 3-year-old child are concerned that the child displays signs of autism spectrum disorder (ASD). What symptoms observed and reported by the parents correlate with the diagnosis of ASD? Select all that apply.

inflexible when scheduled routine changes an inability to maintain eye contact repeats words that are said repeatedly uses a flat tone when speaking

A client has depression after the death of a child. After a suicide attempt, the client is admitted to the inpatient psychiatric unit. During the admission interview, the client reports no longer wanting to die. Which action would be most appropriate for the nurse?

inspect the client's personal belongings for potentially dangerous objects

The nurse is caring for a client who has been diagnosed with narcolepsy. Which actions may assist the client in managing this condition? Select all that apply.

limit caffeine intake avoid smoking follow a regular schedule for sleep and rest

A nurse is providing care to a client diagnosed with bipolar disorder, currently experiencing mania. When reviewing the plan of care for the client, which intervention would the nurse most likely implement at this time?

listening attentively with a neutral attitude, avoiding situations involving increased stimulation

A family member brings a client to the emergency department that has allegedly taken approximately 20 pills from a bottle of narcotics. The nurse obtains a blood pressure of 90/56 mm Hg, heart rate of 46, and a respiratory rate of 10 breaths/minute. What is the priority nursing intervention?

maintain a patent airway

A nurse is caring for a client who is acutely suicidal. When accompanying the client to the bathroom, what is the appropriate action by the nurse?

maintain continuous observation of the client

A nurse is caring for a client with borderline personality disorder. Which nursing intervention has priority?

maintaining consistent, realistic limits

The nurse is caring for a client with dementia. Which nursing action is the priority?

maintaining optimal physical health

A nurse on the psychiatric unit is caring for a client with antisocial personality disorder. Which behavior is the nurse most likely to observe?

manipulation, shallowness, and the need for immediate gratification

The nurse is caring for a client immediately after the client has received electroconvulsive therapy (ECT) for the treatment of severe depression. What is a priority intervention for this client?

orient the client to the surroundings

A nurse observes that a client is mistrustful and shows hostile behavior. Which type of personality disorder is associated with these characteristics?

paranoid

A client diagnosed with major depression states, "Everything is my fault, and I would be better off dead." Which priority intervention would the nurse implement?

place the client on suicide precautions

A client diagnosed with bipolar disorder is receiving a maintenance dosage of lithium carbonate. The client is reported by a family member to be hyperactive and hyperverbal. Which intervention is appropriate?

prepare the client for lithium blood levels

Which nursing intervention would help a client diagnosed with Alzheimer's disease (AD) perform activities of daily living?

provide ample time for the client to complete basic tasks

A nurse is caring for a client diagnosed with late stage Alzheimer's disease (AD). What nursing intervention is priority?

providing supervision

A client with depression doesn't respond to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). The nurse knows that most people respond negatively to the thought of an electric current passing through the brain. Therefore, when discussing ECT with the client, the nurse should:

refer to the procedure as a "treatment" instead of "shock therapy."

A nurse is caring for an adult client in a long-term-care facility who has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?

remove items that the client could use for self-inflicted injury

A physician prescribes lithium for a client with bipolar disorder. Which topics should the nurse cover in the client education for this drug? Select all that apply.

signs and symptoms of drug toxicity need to consistently monitor blood levels changes in mood may take 7 to 21 days

A client taking antidepressants for major depression for about 3 weeks now states " I'm feeling better." Which complication should the client be monitored for?

suicidal ideation

An adolescent becomes increasingly withdrawn, is irritable with family members, and has been getting lower grades in school. After giving away a stereo and some favorite clothes, the adolescent is brought to the community mental health agency for evaluation. This adolescent is at risk for:

suicide.

A client tells the nurse "my cowaorkers are sabotaging my computer." When the nurse asks questions, the client becomes argumentative. Which intervention would be most appropriate for the nurse to implement?

talk with the client about the realistic situations

When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that:

the client has undergone a thorough medical evaluation.

A client with bipolar disorder has abruptly stopped taking prescribed medication. Which behavior would indicate the client is experiencing a manic episode?

thoughtless spending

A nurse is working with a client diagnosed with a bordeline personality disorder. The client gets along poorly with immediate family and exhibits manipulative behavior. What stage of development has the client failed to master?

trust

The nurse is assisting with a care plan for a client admitted with Alzheimer's dementia. The family reports that the client has to be watched closely for wandering behavior at night. Which nursing action will be of the greatest importance?

using a bed check monitor device