Pearson Week 2

A client with a wound infection has been receiving cephalexin 500 mg​ orally, 4 times a day. The lab report shows sensitivity to clindamycin. What action would the nurse expect from the health care​ provider?

The provider will change the antibiotic to clindamycin. (A culture and sensitivity test is performed when infection is suspected. A sensitivity report determines which medication is most effective in treating the infection. The nurse can expect the provider to change the client​'s therapy to the medication that is most appropriate to treat the infection.)

The nurse is caring for a client with a surgical wound. Which are the most appropriate goals for the​ client?

The client will remain free of wound infection. Your answer is correct. The client will maintain adequate hydration. Your answer is correct. The client will be​ comfortable, with pain at an acceptable level. This is the correct answer. The client will engage in activities that promote wound healing (Goals for clients with a healing wound center around adequate​ nutrition, hydration, infection​ prevention, and promotion of optimal wound healing. Pain control is also important for the client. The client should not stop taking prescribed medications without talking to the primary​ provider, even if the medications have the potential to delay wound healing or increase the risk of​ infection, such as corticosteroids.)

A client with depression is admitted to the mental health unit because of attempted suicide. Which​ short-term goal should be given high priority for this​ client?

The client will seek out the nurse when feeling​ self-destructive. (By seeking out a nurse when feeling​ self-destructive, the client can feel safe and begin to discover coping skills to assist in dealing with​ his/her self-destructive tendencies. Identifying actual and perceived​ losses, learning strategies to promote relaxation and​ self-care, and developing healthy caring relationships are all important for the client with depression to​ achieve, but safety is the priority goal for this client to achieve at this time.)

A nurse finds a nurse colleague supporting a client​'s abdomen with a large dressing soaked in sterile normal saline. The client is in bed with knees​ bent, and states that something open double quote gave way.close double quote What does the nurse tell the surgeon has occurred with this​ client?

The client​'s abdominal wound has dehisced or eviscerated. (This scenario describes immediate intervention for wound dehiscence or evisceration. It is not an appropriate intervention for intractable​ pain, malfunction of a​ vacuum-assisted closure​ device, or postop infection.)

Which priority problem should the nurse include when planning care for a client diagnosed with major depressive​ disorder?

Risk for violence directed at self (The priority problem that the nurse needs to include when planning care for a client admitted for major depressive disorder is risk for violence directed at self. A client who is experiencing major depressive disorder may be experiencing suicidal ideations or have recurring thoughts of death. Problems addressing safety issues are priority. Although disturbed body​ image, impaired​ self-care, and risk for social isolation are pertinent​ problems, they are not priority problems.)

The nurse is reviewing orders written for a client demonstrating signs of depression. Which diagnostic test should the nurse expect to be prescribed for this​ client?

Thyroid function (Thyroid function tests may be prescribed for a client demonstrating manifestations of depression because thyroid disorders can mimic depression. Serum electrolytes would be prescribed for the client demonstrating signs of substance abuse. White blood cell count and hemoglobin and hematocrit levels are not prescribed to determine a physical cause for depression.)

The nurse is admitting a client to the mental health unit for possible persistent depressive disorder. What data should the nurse collect when completing the client​'s physical​ assessment?

Vital signs (When completing a physical assessment on a client being admitted to a mental health​ unit, the nurse needs to obtain vital signs. Suicidal​ ideations, medication​ use, and sleep disturbances are data that the nurse needs to obtain when completing the health history.)

The nurse is educating a student about alginate dressings. On what type of pressure ulcer is this type of dressing​ used?

Stage II Stage III Stage IV without eschar (Alginate dressing should be used for pressure ulcers of stage​ II, III, and IV without​ eschar, but not for pressure ulcers of stage I or stage IV with eschar. An alginate dressing is not used for stage​ I, Alginate calcium Tegaderm can be used with stage I.)

A client with type 1 diabetes mellitus has a blister on the left heel that resulted from improperly fitting shoes. The nurse should document this ulcer as being which​ stage?

Stage II (A stage II pressure ulcer is considered to be superficial and appears as a blister. Stage I ulcers have intact skin that doesn​'t blanch when pressed. Stage III pressure ulcers are deep open wounds with necrosis of subcutaneous tissue. Stage IV pressure ulcers have​ full-thickness skin loss with extensive tissue damage and necrosis.)

The nurse is caring for a client with a pressure ulcer on the right elbow that is covered with eschar. The nurse should document this ulcer as being which​ stage?

Stage IV (A stage IV pressure ulcer may be covered with eschar. Eschar is not present with stage​ I, stage​ II, or stage III pressure ulcers.)

At the conclusion of a health​ history, the nurse is concerned that a​ middle-aged client is experiencing physical manifestations of depression. What did the nurse assess to come to this​ conclusion?

States a considerable loss of energy Clothing​ rumpled; hair not washed or combed Your answer is correct. Inability to recall the last time ingested food (e Physical manifestations of depression include a loss of​ energy, lack of​ appetite, and appearing unkempt with poor hygiene. Sleeping 1 to 2 hours each night is a physical manifestation of mania. Tearfulness is an affective characteristic of depression.)

The nurse carefully inspects a skin lesion that the nurse believes is due to contact dermatitis. Besides​ inspection, what other technique is important for the nurse to use during the nursing assessment of this​ client?

Palpation (Besides​ observation, the nurse will palpate the lesion to determine its surface characteristics. The nurse will not use percussion or auscultation techniques. Nurses do not perform biopsies.)

The nurse is planning care for a client with seasonal affective disorder​ (SAD). After which intervention would the nurse expect to see improvement in emotional​ stability?

Phototherapy (The lack of or diminution of sunlight causes an exacerbation in depression symptoms in clients with SAD and evaluation of fatigue and depression should be assessed by the nurse after phototherapy.​ ECT, massage​ therapy, yoga, and meditation are not primary therapies for SAD.)

An​ 88-year-old client who has limited mobility is admitted to the hospital. Which action by the nurse prevents injury to the skin normally caused by​ friction?

Placing the client in the prone position (To prevent injury to the skin caused by​ friction, the client should be turned every 2 hours using six different body​ positions, which include the prone position. Elevating the head of bed to a​ 60-degree angle, not using a draw​ sheet, and using baby powder cause injury to the skin as a result of friction.)

The mother of an adolescent diagnosed with depression was hoping that the child would not have the problem even though both she and her spouse struggle with depression every day. Which is the best response by the nurse to the​ mother?

The genetic risk for children to be diagnosed with depression is greatest if both parents have the disorder. (Children of depressed parents have twice the risk of experiencing depression over a lifetime. If both parents have​ depression, the risk rises to​ 75%. Depression in adolescence is not a minor disorder since​ 11.2% of adolescents between the ages of 13 and 18 have been diagnosed. There is no evidence to suggest that an adolescent will outgrow the symptoms of depression. There is no evidence to support that there aren​'t treatments designed for adolescents with depression.)

A client is demonstrating extreme​ excitement, inability to sit​ still, agitation, and states she is the First Lady of the United States. It appears the client is having a manic episode. What additional characteristic might the nurse find in this​ client?

Endless energy (Mania is characterized by an abnormal and persistently​ elevated, expansive, or irritable mood lasting at least 1​ week, significantly impairing social or occupational​ functioning, and often requiring hospitalization. The nurse will find the client has endless​ energy, not depression. The client may be​ aggressive, not passive. The client may also have rapid​ speech, not slowed speech)

A client who is confined to bed is at risk for developing a pressure ulcer. What support surface should the nurse request for this​ client?

Kinetic bed (For clients who are confined to​ bed, the support surface needs to include a kinetic bed that provides oscillation therapy. Gel flotation​ pads, a memory foam​ mattress, and an alternating pressure mattress help to reduce pressure on specific body parts but are not the recommended support surface.)

A​ client, who usually demonstrates an appropriate​ affect, becomes irritated and angry after learning that a community health clinic is closing and care will need to be obtained 20 miles away. What should the nurse suspect as being the reason for this client​'s change in​ affect?

Location of the clinic 20 miles away (Environmental influences strongly impact the ability to regulate one​'s mood intensity and shift. After learning that a community clinic is closing and the next closest one is 20 miles​ away, the client becomes irritated and angry. There is no information to support that the client​'s irritation and anger is because of an underlying health​ problem, length of time the community clinic was the location to receive​ care, or the relationship with the person sharing the news about the clinic closing.)

A severely depressed client received electroconvulsive therapy​ (ECT) this morning. Which finding would the nurse recognize as normal​ posttreatment?

Memory loss (Following an​ ECT, the nurse can expect​ transient, short-term memory loss. Paralytic​ ileus, hypotension, and shallow respirations are not normal findings following an ECT.)

The nurse is conducting a​ follow-up interview with a client using alternative therapy to aid in the treatment of depression. Which observations indicate that yoga therapy has been helpful for this​ client?

Motivated to return to work Your answer is correct. Expressed satisfaction with treatment Attentive during the interview (Yoga has been found to improve life​ satisfaction, attentiveness, motivation and energy in clients with depression. Experiencing chronic headaches and fatigue indicates that yoga has not been effective in the treatment of depression in the client.)

A nurse is caring for a client with bipolar disorder who is being treated for this condition with lithium carbonate. Upon​ assessment, the nurse notes that the client​'s lower extremities appear swollen. What is the nurse​'s best response to this clinical​ finding?

Notify the healthcare provider immediately. (Edema of the lower extremities may indicate lithium carbonate toxicity. The nurse should notify the healthcare provider immediately. The other answer choices are not appropriate as the best response.)

The client states to the​ nurse, "I take citalopram​ (Celexa) 40 mg every​ day, and I have also been taking St. John​'s wort 750 mg daily for the past 2​ weeks." Which manifestations would lead the nurse to suspect that the client is developing serotonin​ syndrome?

Diaphoresis Your answer is correct. Ataxia Your answer is correct. Headache Your answer is correct. Confusion (Serotonin syndrome can occur if a selective serotonin reuptake inhibitor is combined with a monoamine oxidase​ inhibitor, a​ tryptophan-serotonin precursor, or St. John​'s wort. Signs and symptoms of serotonin syndrome include restlessness or​ agitation, headache,​ diaphoresis, ataxia,​ myoclonus, shivering,​ tremor, diarrhea,​ nausea, abdominal​ cramps, and hyperreflexia. Constipation is not associated with serotonin syndrome.)

The nurse is teaching a young adult client about risk factors likely to cause allergic skin reactions. Of the​ possibilities, which ones would the nurse identify as possible risk​ factors?

Exposure to soap Exposure to plants Exposure to perfumes (Soaps, perfumes, and other chemicals are possible triggers of allergic skin reactions. Plants like poison ivy are also triggers for allergic contact dermatitis. Moist environments and frequent hand​ washing, rather than dry environments and infrequent hand​ washing, are also risk factors for developing contact dermatitis.)

The nurse is planning care for a client with bipolar disorder who is experiencing mania. What outcomes are appropriate for the nurse to include in the client​'s plan of​ care?

The client will demonstrate socially appropriate behaviors during interactions with others in a variety of settings. Your answer is correct. The client will maintain a safe environment and remain free from injury. The client will not commit violent or harmful acts against self or others. The client will get at least 6 hours of sleep per night. (A goal that states the client will not experience any additional episodes of mania is​ incorrect, because this is not specific to the client​'s problem right now. The other​ outcomes/goals are appropriate for a client with bipolar disorder experiencing mania.)

The nurse is planning care for a client with bipolar disorder who is experiencing depression. What outcomes are appropriate for the nurse to include in the client​'s plan of​ care?

The client and family will become knowledgeable about the​ disorder, effective​ communication, and problem solving. The client will have no suicidal ideations. The client will maintain a safe environment and remain free from injury. The client will maintain appropriate personal​ self-care. (A goal that states that the client who is currently depressed will have no symptoms of depression is inappropriate. All other answer choices are appropriate choices for the client with bipolar disorder with depression.)

The nurse is providing care for a client with a wound infection. Which diagnostic test is necessary to determine the antibiotic choice for this​ client?

Culture and sensitivity (A client diagnosed with a wound infection will require a culture and sensitivity prior to the initiation of antibiotic therapy. The other diagnostic tests may be​ ordered, but the culture and sensitivity will be used to determine the most appropriate antibiotic to treat the client​'s wound infection.)

A nurse is caring for a client with bipolar disorder who is admitted to the hospital after an accidental overdose of sleeping medication. What are appropriate nursing diagnoses for this​ client?

Impaired knowledge about the disease process Impaired coping mechanisms Risk for altered nutritional status Potential for appropriate medication management (Appropriate nursing diagnoses for a client with bipolar disease who is displaying mania​ include: Impaired knowledge about the disease​ process; potential for appropriate medication​ management; risk for altered nutritional​ status; and impaired coping mechanisms. The client with mania who has overdosed on medication has an impaired knowledge about his or her disease and has a potential for appropriate medication management. The client with mania is also at risk for altered nutritional status due to the decreased need for eating. The client with mania who overdoses on medication has impaired coping mechanisms. It is not known if the client has alterations in interpersonal relationships. This information may be obtained in a psychosocial assessment.)

A client is being assessed by the health care provider for potential therapies for his sternal​ wound, which include hyperbaric oxygen​ therapy, skin​ grafting, and biosurgery. What would the nurse expect to observe when visualizing the​ client's wound?

Wound has impaired healing Wound has necrotic tissue or slough (There are several therapies that may be useful for wounds with impaired healing. Hyperbaric oxygen therapy improves oxygenation in nonhealing wounds. Skin grafts may be appropriate for some clients with nonhealing wounds. Biosurgery with sterile maggots may be used in wounds with necrotic tissue and slough to digest the unhealthy tissue. The size of the wound​ doesn't determine the treatment. An eviscerated wound requires surgery. Wounds in maturation are healed.)

The nurse is caring for a client with a surgical wound. Which finding would indicate the need for further​ intervention?

Wound is red and edematous with a foul odor (Assessment data that require further intervention is a wound that is​ red, edematous, and has a foul odor. These findings indicate a wound infection. The other assessment findings are expected and would not require further intervention by the nurse.)

The nurse is providing education to a client with allergic contact dermatitis caused by a new brand of sunscreen. Which statement made by the client indicates appropriate understanding of the teaching​ session?

​"I have been sleeping well since I started using the corticosteroid​ cream." (If the client is sleeping​ well, then pruritus has been properly managed. The client should avoid the precipitating​ allergen, not use it less frequently. If the​ client's rash is newly hot and​ painful, this could be a sign of an infection that necessitates further treatment. Allergic contact dermatitis should be treated with drying lotions and​ treatments, not emollients that prevent water loss like petroleum jelly.)

The nurse is performing a scratch test on a client with suspected allergic contact dermatitis. The client​ states, "I​ don't understand why​ I'm only getting this reaction now. This​ didn't happen to me the first time I used this​ detergent." Which response by the nurse is the most​ appropriate?

​"The first contact sensitized you to the allergen. You​ don't have an allergic reaction until the next exposure to the​ allergen." (With allergic contact​ dermatitis, the first exposure to the allergen sensitizes the client to the​ allergen, and manifestations of the allergy do not manifest until subsequent exposures. Stating that sometimes it takes time for the body to react does not explain the process to the client. With allergic contact​ dermatitis, removing the allergen does not guarantee rapid resolution of symptoms. In some​ cases, symptoms may remain for up to three weeks. Explaining the course of the condition also does not answer the​ client's question. The explanation of the pathology of allergic contact dermatitis may be too technical for the client and does not answer the​ client's specific question about the timing of symptoms.)

The nurse is applying ointment to the affected skin area of a client with contact dermatitis. The client asks the nurse how this treatment is different from what was prescribed for the allergic dermatitis her husband had. Which response by the nurse is the most​ appropriate?

​"Treatment for irritant contact dermatitis focuses on reducing water loss from the​ skin." (Because irritant contact dermatitis manifests with​ dry, scaling​ skin, treatment focuses on reducing water loss from the skin through the use of occlusive dressings and​ petroleum-based emollients. Allergic contact​ dermatitis, not irritant contact​ dermatitis, is treated with corticosteroids and by drying out the rash. Topical antibiotics are only used if the client develops a secondary infection.)

A client is diagnosed with a severe case of allergic contact​ dermatitis, which covers​ 20% of the​ client's body. Which treatment can the nurse anticipate will be prescribed for this client that is specific to severe allergic contact​ dermatitis?

Oral corticosteroids (The nurse can anticipate the healthcare provider ordering oral corticosteroids for a client with a severe case of dermatitis. Antipruritic medications will be ordered for a client with a minor case of​ dermatitis, not a severe case. Wet dressings will be ordered if the client has dermatitis with weeping​ lesions, regardless of whether or not the dermatitis is severe. Topical antibiotics will be ordered if the client has dermatitis that has lesions with secondary​ infections, regardless of whether or not the dermatitis is severe.)

he nurse is planning care for a client diagnosed with major depressive disorder. Which activity should the nurse encourage the client to participate in based on the​ diagnosis?

Playing a card game (When caring for a client with major depressive​ disorder, the nurse should involve the client in recreational activities and conversation that provide distraction from​ self-absorption and negative thoughts. Playing a card game encourages participation in a nonthreatening activity while engaging with others. Reading a​ book, watching​ television, and listening to music are activities that can be completed independently and do not encourage conversation or activities with others.)

While assessing the skin of a surgical​ client, the nurse observes erythema to the left scapulae. What is the best action for the nurse to take before reassessing the skin to determine if the erythema is a pressure​ ulcer?

Repositioning the client (The nurse needs to reposition the client to remove pressure from the scapulae and then reassess for redness in​ one-half or​ three-fourths the time it took to create the reddened area. If the reddened area does not​ clear, the client has a stage I pressure ulcer. Massaging the scapulae with​ lotion, applying a warm​ blanket, or covering the area with a dressing is not the best action before reassessing the client.)

The nurse is discussing alternative therapies with the mother of a pediatric client with chronic contact dermatitis. Which therapies would the nurse​ suggest?

Rice bran broth Probiotics Aloe vera (Aloe vera​ (applied topically), rice bran broth​ (used to bathe the​ skin), and probiotics​ (administered orally) are all common alternative therapies used to relieve symptoms of contact dermatitis in pediatric clients.​ Chamomile, not​ peppermint, and vitamin​ B12, not vitamin​ C, are other alternative​ therapies, although vitamin B12 may aggravate contact dermatitis in some cases.)

The nurse is assessing a client with a red rash on the leg. Which assessment findings will differentiate the rash as allergic or irritant contact​ dermatitis?

Scaling (Both allergic and irritant contact dermatitis cause​ erythema, edema, and vesicles.​ However, only irritant contact dermatitis causes scaling and skin dryness.)

The nurse is completing a health history on a client with seasonal affective disorder​ (SAD). What data should the nurse obtain during this​ interview?

Anhedonia Your answer is correct. Medical history Your answer is correct. Sleep disturbances Your answer is correct. Feelings of guilt (When completing a health history on a client with seasonal affective​ disorder, the nurse needs to obtain information regarding sleep​ disturbances, medical​ history, feelings of​ guilt, and anhedonia​ (decreased ability to experience​ pleasure). The client​'s sexual history is not pertinent when completing the health history on this client.)

The nurse identifies that a client admitted for decreased mental status is at risk for a pressure ulcer. Which action assists in maintaining skin hygiene to help prevent a pressure​ ulcer?

Applying lotion to moist skin after the bath (Moisturizing lotions applied directly to moist skin after bathing help maintain skin hygiene and prevent pressure ulcers. Massaging bony prominences can cause friction. Using hot water to bathe the client can dry the skin and cause​ injury, A skin assessment is done on admission and then daily.)

While reviewing previous​ documentation, the nurse notes that a client is described as demonstrating passive behavior. What should the nurse expect when communicating with this​ client?

Avoiding conflict or confrontation Your answer is correct. Unexpected explosions of anger (Characteristics of passive behavior include unexpected explosions of anger and avoiding conflict or confrontation. Intimidating others and lacking consideration for others​' feelings are characteristics of aggressive behavior. Expressing feelings but not at the expense of others is a characteristic of assertive behavior.)

A nurse is providing discharge instructions for a client with bipolar disorder who presented to the hospital in a manic state. What instructions will the nurse include in the home care instruction of the client with bipolar​ disorder?

Seek help when needed. Your answer is correct. Recognize medication side effects. Your answer is correct. Learn effective​ self-administration of medications. Recognize the importance of adhering to therapy schedules. (Home care instruction for the client with bipolar disorder​ includes: Recognizing medication side​ effects, seeking help when​ needed, learning effective​ self-administration of​ medications, and recognizing the importance of adhering to therapy schedules. Bipolar disorder cannot be prevented.​ However, the disorder may be treated.)

While applying lotion to the skin of an older​ client, the client asks why it is more important to take better care of her skin now than when he was younger. Which dermatological features will the nurse describe to the​ client?

Decreased turnover of the outer skin layer Your answer is correct. Impaired skin barrier function Your answer is correct. Greater sensitization to allergens over time (With​ age, the turnover of the outer skin layer of the skin​ (stratum corneum)​ decreases, which results in​ slower, not​ faster, wound healing. With​ age, greater exposure and sensitization to allergens​ occurs, causing older adults to be at greater risk for allergic contact dermatitis. Older adults also have impaired skin barrier function.​ However, older adults are less likely to develop irritant contact dermatitis due to the​ decreased, not​ increased, efficiency of blood circulation to the skin.)

The nurse is reviewing the pharmacological profile of a client with a nonhealing wound. Which of the​ client's medications can delay wound​ healing?

Dexamethasone​ (Decadron) (Corticosteroid agents interfere with wound healing. Digoxin increases the contractility of the heart but has no direct relationship to wound healing. Hydrocodone is an analgesic with no direct association with wound healing. Esomeprazole is a proton pump inhibitor not associated with wound healing.)

The nurse is assessing a new client on the mental health unit. The client states that she has been depressed most of the time for the past 2​ years, is unable to cope with family​ responsibilities, and has frequent thoughts of suicide and death. Based on these​ data, which type of diagnosis does the nurse​ anticipate?

Dysthymic disorder (Clients who are diagnosed with dysthymic disorder demonstrate a depressed mood most of the time for 2 years​ (for adults), are unable to cope with​ responsibilities, and have thoughts of suicide and death. Other symptoms include​ self-pity, chronic​ fatigue, poor​ self-esteem, difficulty​ concentrating, and pessimism about the future. Seasonal affective disorder occurs when the individual experiences depression during the fall and winter seasons. Bipolar disorders are a group of mood disorders that include manic​ episodes, hypomanic​ episodes, and mixed episodes. Symptoms may include​ euphoria, inability to take time to​ eat, sleep​ disturbances, and possibly sexual disinhibition. Cyclothymic disorder symptoms include fluctuating mood disturbances involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms.)

A client​'s spouse complains that his wife​'s depression isn​'t any better after taking an antidepressant medication for 1 week. What action should the nurse initially​ take?

Explain that it may take 1dash 3 weeks to see any improvement. (A client may need to take an antidepressant for 1dash 3 weeks before any improvement or therapeutic effect is noticed. Calling the healthcare provider or changing antidepressants is inappropriate at this time. The medication effects need to be assessed according to guidelines and therapy can be implemented at the appropriate time according to the healthcare provider​'s assessment.)

The mother of twin toddler girls asks the nurse to separate them at the time of annual inoculations because they will both open double quote fly off the handleclose double quote at the same​ time, making it difficult to control the situation. Which information about affect is this mother describing to the​ nurse?

Genetic influence (A study of twins indicated that mood intensity and lability seemed to support a strong genetic influence. Separating the twins would reduce the emotional lability when a stressful event was going to occur. The mother​'s request is not to prevent copycat behavior. It is not known if the twins have a fear of injections. The mother is not making this request because of normal toddler behavior.)

The nurse is planning care for a client with bipolar disorder. Which intervention would the nurse implement to maintain adequate nutrition during a manic​ episode?

Give the client foods to be eaten while the client is active. (By giving the client​ high-calorie foods that can be eaten while the client is​ active, the nurse facilitates the client​'s nutritional intake. The client​'s metabolic rate is not useful information when the client is experiencing mania. The client will not be able to sit still long enough to focus on what the dietitian is saying during a manic episode or to sit in the dining area to eat.)

The nurse is caring for a client with a stage I pressure ulcer to the sacrum. Which product should the nurse use to help increase blood supply to the skin of this pressure​ ulcer?

Granulex (Granulex is a product that increases blood supply to the intact skin of a stage I pressure ulcer. A transparent or hydrogel dressing does not increase blood supply to intact skin of a stage I pressure ulcer.​ Vacuum-assisted closure increases the blood supply but should only be used on a stage IV pressure ulcer.)

The nurse is preparing an educational seminar on depression for a community health fair. Which strategies should the nurse include to reduce depressive​ episodes?

Have regular visits with the healthcare provider Your answer is correct. Obtain adequate rest Your answer is correct. Build a strong support system Your answer is correct. Be aware of family risk factors (Strategies to reduce the onset of depressive episodes include obtaining adequate​ rest, building a strong support​ system, being aware of family risk​ factors, and having regular health appointments with the healthcare provider to detect symptoms of depression early. Alcohol intake should be limited to prevent the onset of substance abuse disorders.)

A client has just undergone femoral popliteal bypass surgery and has an incision with staples in the right groin. The nurse assesses a large swelling around the incision and notes that the right thigh is noticeably larger than the left. The client is pale and diaphoretic with a blood pressure of​ 72/48 mmHg. Which complication would the nurse​ suspect?

Hemorrhage (Internal hemorrhage may be seen as a swelling or distention in the surgical area. It can be caused by a clot dislodging or a missed​ suture, among other things. It is an emergency that requires pressure to be applied to the area. The client may need to go back to the operating room. Wound​ infection, dehiscence,​ evisceration, and keloid formation generally occur later in the process and do not present with these symptoms.)

During a health history​ assessment, the nurse first believed that a client was experiencing manifestations of grief until a specific comment was made. What did the client state that helped the nurse determine that the client is experiencing​ depression?

I am a complete failure. (The individual experiencing depression has low​ self-esteem, low​ self-confidence and feels like a failure. Having pain and emptiness are characteristics of grief. Being persuaded to participate in activities is a characteristic of grief. Believing that everything that could have been done was done indicates intact​ self-esteem which is a characteristic of grief.)

The spouse of a client who passed away a few moments ago is sitting in the room staring into space. When asked if there is anything that can be done at this​ time, the spouse begins to laugh. Which terms should the nurse use to describe the spouse​'s affect at this​ time?

Inappropriate Flat (The spouse​'s reaction of staring into space is flat since there are no visible emotional cues. Laughing at the question demonstrates an inappropriate affect since the response is not congruent with the situation. Dramatic is not a term used to describe affect. An appropriate affect demonstrates congruency with the immediate situation. An​ over-reactive affect is one that is out of proportion to the immediate situation.)

A client is being admitted for treatment of major depressive disorder. Which symptom should the nurse anticipate the client would experience during​ hospitalization?

Insomnia (The nurse should anticipate that a client experiencing major depressive disorder would have insomnia. A client with major depressive disorder will experience psychomotor​ retardation, decreased​ libido, and feelings of worthlessness or excessive guilt.)

When planning care for a client at risk for developing a pressure​ ulcer, the nurse addresses the potential problem of risk for impaired skin integrity. Which nursing intervention assists in meeting the goals of this​ diagnosis?

Inspecting the skin every day Using positioning devices Avoiding massaging bony prominences (Using positioning devices such as pillows or foam wedges to protect bony​ prominences, not massaging bony​ prominences, and inspecting the skin daily help prevent skin breakdown and assist in meeting the goals of this diagnosis. Avoid placing the client in a​ side-lying position only or keeping the head of bed elevated more than thirty degrees because these positions can put pressure on specific body areas.)

The nurse is caring for a client admitted with a pressure ulcer. Which data should the nurse document when assessing the pressure​ ulcer?

Integrity of the surrounding tissue Signs of infection Stage of the ulcer Color of the wound bed (Document the stage of the pressure​ ulcer, color of the wound​ bed, integrity of the surrounding​ tissue, and signs of infection. Assessment of home management does not need to be documented.)

A client with allergic contact dermatitis is scheduled for a skin test in which small amounts of an allergen will be injected into the skin on the arm. Which test will the nurse educate this client about prior to​ performing?

Intradermal test (An intradermal test involves the injection of small amounts of allergen into the skin on the arm. A patch test involves the application of an adhesive patch with common allergens on the back. A scratch test involves the application of small amounts of allergens to the skin. An IgE antibody test is a blood test for allergen antibodies.)

A client in an outpatient mental health clinic is diagnosed with cyclothymic disorder. Which statement about cyclothymic disorder is​ true?

It involves a mood range from moderate depression to hypomania. (Cyclothymic disorder involves a mood range from moderate depression to hypomania. Bipolar I disorder is characterized by a single manic episode with no past major depressive episodes. Seasonal affective disorder is a form of depression occurring in the fall and winter.)

At the conclusion of an appointment with a behavioral​ therapist, a client with anger management issues asks the nurse why the therapist believes the client needs to start taking serotonin. Which response should the nurse make to the​ client?

It is associated with aggressive behavior. (A serotonin deficiency is associated with​ anxiety, aggression, and​ self-destructive behavior. Serotonin does not affect excitability. An acetylcholine deficiency is associated with sleep disorders. The protein P11 manages how brain cells respond to serotonin.)

A nurse is caring for a female client with bipolar disorder. The healthcare provider has prescribed lithium carbonate for the collaborative treatment of the client​'s condition. What information will the nurse include in the client teaching regarding this​ medication

Lab work will be needed to monitor the therapeutic level of this medication. Monitor for nausea and​ vomiting, as this could indicate a lithium toxicity. This medication should not be used if you suspect you may be pregnant. This medication may be used with an antipsychotic mood stabilizer. (​Nausea, vomiting, and diarrhealong dash not constipationlong dash are symptoms of lithium toxicity. Lithium carbonate should not be used in pregnant clients and may be used in combination with antipsychotic mood stabilizers. Lab work is needed to monitor the therapeutic level of this medication.)

The nurse is writing a plan of care for a client with acute mania. Which nursing interventions are appropriate when caring for this​ client?

Maintain proper client nutritional status. Your answer is correct. Discuss sleep patterns and methods to promote at least 6 hours of sleep at night. Your answer is correct. Administer medications as ordered. Your answer is correct. Assist with personal hygiene as needed. (Appropriate nursing interventions for the client experiencing mania​ include: Administering medications as​ ordered, maintaining proper client nutritional​ status, assisting with personal hygiene as​ needed, and discussing sleep patterns and methods to promote at least 6 hours of sleep at night. The nurse should not encourage the client with mania to sit while​ eating, as this is very difficult or impossible for the client to do.)

A​ 42-year-old was admitted to the mental health unit after a failed suicide attempt by drug overdose. The client sought help when her husband informed her of his decision to leave her and the children after 21 years of marriage. Upon initial contact with the​ nurse, the client looked​ exhausted, affect was​ sad, movements and responses were​ slowed, and​ self-care impairments were evident. What type of disorder would the nurse suspect the client is​ experiencing?

Major depressive disorder (Major depressive is evidenced by psychomotor​ retardation, impairment of​ self-care, inability to​ sleep, and a suicide attempt. Bipolar disorder is characterized by hyperactivity and euphoria that may become sarcasm or hostility. Adjustment disorder with depressed mood is a change in mood and affect following a​ stressor, such as the end of a relationship. It is also called situational depression. Dysthymic disorder has symptoms of normal moods for a period of​ weeks, followed by​ depression, insomnia/hypersomnia, loss of interest in​ activities, and social withdrawal.)

A nurse identifies that a client has a pressure ulcer on the sacrum. Which assessment finding indicates that this is a stage III pressure​ ulcer?

Necrosis of subcutaneous tissue (This client has a stage III pressure​ ulcer, which indicates that damage to the subcutaneous tissue has occurred. The necrosis extends down to but not through the underlying fascia. Exposed muscle and bone indicates a stage IV pressure ulcer. An area of nonblanchable erythema of intact skin indicates a stage I pressure​ ulcer, and skin loss to the dermis indicates a stage II pressure ulcer.)

The nurse is evaluating the effectiveness of the nursing interventions for a client with bipolar disorder. Which evaluation of outcomes are appropriate for this​ client?

The client did not commit violent or harmful acts against self or others. This is the correct answer. The client was able to set appropriate limits in a variety of situations. Your answer is correct. The client was able to demonstrate​ reality-based thinking by making an effective decision. Your answer is correct. The client remained in a safe environment and free from injury. (The client with bipolar disorder should sleep at least 6​ hours, not​ 4, at night. All other evaluations are appropriate for this client.)

The nurse is assessing a client with a large abdominal surgical wound. Which assessment would concern the nurse that puts the client at risk of the complication of​ dehiscence?

The client is​ obese, with a BMI of 38. Your answer is correct. The client has vomited 6 times in the last 4 hours. This is the correct answer. The client shows signs of dehydration. (Dehiscence usually involves an abdominal​ wound; the layers above and below the skin separate. The bowel may protrude into the opening. Risk factors for dehiscence include​ obesity, poor​ nutrition, multiple​ trauma, suture​ failure, excessive​ coughing, vomiting, or dehydration. It is most likely to occur 4dash 5 days postoperatively. Smoking is not an identified risk factor for dehiscence.)

The charge nurse has just received the report for all clients on the unit. Which client should the nurse consider as being at risk for the development of pressure​ ulcers?

The client who is 92 years old Your answer is correct. The client who is on bed rest Your answer is correct. The client who has a history of anorexia nervosa Your answer is correct. The client who has type 1 diabetes mellitus (A client on bed rest is​ immobile, which creates a risk for developing pressure ulcers. An older client is at risk because of the loss of lean body​ mass, epidermal​ thinning, decreased skin​ elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissue. A client with a history of anorexia nervosa is at risk because of inadequate​ nutrition, which leads to weight​ loss, muscle​ atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure ulcer.)

A nurse is caring for a client with bipolar disorder. The healthcare provider has prescribed olanzapine​ (Zyprexa) for the collaborative treatment of the client​'s condition. What information will the nurse include in the client teaching regarding this​ medication?

This medication is called an antipsychotic mood stabilizer. This medication is often taken with an anticonvulsant mood stabilizer (Olanzapine​ (Zyprexa) is an antipsychotic mood stabilizer that is often taken with an anticonvulsant mood​ stabilizer, not an anxiolytic. Lithium​ carbonate, not​ Zyprexa, must be monitored with a blood test.)

A client is prescribed electroconvulsive therapy as treatment for depression. What should the nurse review with the client about these​ treatments?

Treatments will be 3 times a week for 12 treatments. (Electroconvulsive therapy is the passing of an electrical current through the brain. Treatments are given​ 2-3 times a week for 12 treatments. Symptoms improve within 1 to 2 weeks with transcranial magnetic stimulation. A magnetic field is passed through the skull and targets the left prefrontal cortex with transcranial magnetic stimulation. .)

The nurse is to apply an elastic bandage over a​ client's wound on the right arm. Which nursing assessment should be completed before applying this​ bandage?

Wound drainage (Before applying the​ bandage, the​ client's limb should be inspected for the presence of wound drainage. If drainage is​ present, a dressing is required before applying the elastic bandage. Adequacy of circulation in the limb would be assessed after the dressing has been applied. Pain assessment can be done at any time prior to the application of the bandage. The​ client's ability to reapply the bandage is not a priority before applying the bandage.)

The nurse is performing a health history on a client who has been intermittently experiencing a​ red, itchy rash on the feet for the past 2 months. The client thinks it may be wool socks that are causing the rash. Which assessment question will allow the nurse to distinguish whether the client has allergic or irritant contact​ dermatitis?

"Does the rash go away quickly after you take the socks​ off?" (Asking about the course of the rash is the best way to distinguish between allergic and irritant contact dermatitis because irritant contact dermatitis resolves quickly after removal of the irritant. Allergic contact dermatitis may linger for up to 3 weeks following removal of the allergen. Asking about the severity of itching would not help distinguish between the two types of contact dermatitis. Asking if the rash looks redder or if fever accompanies the rash helps assess for the presence of infection but does not help distinguish between the two types of contact dermatitis.)

A client who has bipolar disorder and is in a manic phase has been taking lithium carbonate 600 mg orally 3 times per day for 14 days. What serum lithium level does the nurse note is​ therapeutic?

0.8dash1.2 ​mEq/L (It takes 10dash 21 days to achieve a lithium level within the therapeutic range. During an acute manic​ episode, the normal therapeutic range is 0.8dash 1.2 ​mEq/L. At higher​ dosages, the client would be exhibiting signs and symptoms of toxicity.)

The nurse is assessing a new client on the mental health unit. The client states that she has been overly busy every day most of the time for the past 2 years and is unable to cope with family responsibilities. The nurse suspects that this client is suffering from which type of​ disorder?

Bipolar disorder with mania (Bipolar disorders are a group of mood disorders that include manic​ episodes, hypomanic​ episodes, and mixed episodes. Symptoms may include​ euphoria, inability to take time to​ eat, sleep​ disturbances, and possibly sexual disinhibition. Cyclothymic disorder symptoms include fluctuating mood​ disturbances, involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. Hypomania is a less extreme form of mania that is not severe enough to markedly impair functioning or require hospitalization. A depressed episode occurs when manic or hypomanic episodes have occurred in the​ past, but the features of the current episode are purely depressive.)

The nurse is visiting the home of a new mother and​ full-term infant. During the course of the​ visit, the nurse suspects that the mother is experiencing early signs of postpartum depression. How did the nurse come to this​ conclusion?

Client scored 13 on the Edinburgh Postnatal Depression Scale (A score of 12 or above on the Edinburgh Postnatal Depression Scale indicates a greater chance of experiencing postpartum depression. The CAGE questionnaire is used to determine alcoholism or drinking behavior. It is not a screening tool for depression. The Cornell Depression Scale is for older clients with severe cognitive impairments. A score of 12 or above on this scale indicates the need for further assessment. The Center for Epidemiological Studies Depression Scale is a tool used for adults. A score of 16 or above on this scale designates depression.)

A client is admitted to a mental health unit for depression. After a​ week, the client continues to withdraw from others. Which statement by the nurse would most likely promote interaction with other​ clients?

Come and play cards with me. (Inviting the client to interact with the nurse in an activity slowly engages the client in a nonthreatening activity with others. The other comments tell the client what​ he/she should do instead of offering the client a means to interact.)

A client diagnosed with major depressive disorder is admitted to the mental health unit because of attempted suicide. The nurse identified the problem of impaired​ self-care. Upon​ evaluation, What data indicate that the client achieved the outcome identified for this​ problem?

Competes shower and brushes teeth independently (Completing a shower and brushing teeth independently indicate that the client is meeting the outcome established by the nurse for the problem of impaired​ self-care. Talking to the nurse about suicidal ideations helps the client achieve the problem of risk for violence directed at self. Identifying the importance for CBT and attending yoga class assist the client in achieving the outcomes identified for the problem of alterations in coping mechanisms.)

During morning​ report, the nurse learns that a client​'s affect is flat. What should the nurse expect when interacting with this​ client?

Complete lack of emotional response (With a flat​ affect, there are no visible cues to the person​'s emotions. Affect that suddenly changes in a way that cannot be understood in the context of the situation is labile. Engaging in meaningful conversation would be consistent with an appropriate affect. Affect that is appropriate but out of proportion to the immediate​ situation, such as loudly stating the joy of being​ hospitalized, is​ over-reactive.)

At the conclusion of a health​ interview, the nurse suspects a​ middle-aged adult female client is experiencing​ seasonal-affective disorder. What did the nurse assess to make this​ determination?

Constant fatigue Your answer is correct. Irritability Your answer is correct. Sadness Your answer is correct. Crying (Manifestations of​ seasonal-affective disorder include​ crying, sadness,​ irritability, and fatigue. Negative thoughts can lead to feelings of incompetence and unworthiness which are not associated with​ seasonal-affective disorder.)

The nurse is completing discharge teaching for a client with a skin infection related to contact dermatitis. Which information should the nurse include to assist the client in managing this skin infection at​ home?

Seek medical attention if lesion becomes painful Avoid allergen that caused initial lesion Use mild soap to clean skin Keep nails trimmed short (The nurse needs to include client education on avoiding the precipitating allergen and using a mild soap to avoid further irritating the skin while at home. The nurse needs to include client education on seeking medical attention if lesion becomes​ painful, which will assist in wound healing. The nurse needs to include client education on the importance of practicing personal hand​ hygiene, which will assist in wound healing and avoid the spread of infection. The nurse needs to include client education on keeping the nails trimmed​ short, which will prevent additional skin damage if the lesion is accidentally scratched. Stopping antibiotics when redness disappears will not assist in wound healing. It is important that the nurse provides client education on completing the full course of antibiotics as prescribed.)

The nurse is caring for an adolescent client diagnosed with depression. Which assessment findings support this​ diagnosis?

Self-neglect (Self-neglect is a manifestation of depression in an adolescent client. Whininess is a manifestation of depression in a preschool child. Boredom and threats to run away are manifestations of depression in a​ school-age client.)

Julie Smith is a​ 44-year-old client who underwent a left mastectomy 2 days ago. Which factor will put Ms. Smith at the highest risk of a wound​ infection?

Starting chemotherapy in 1 week (Eating a balanced diet high in​ protein, and exercising and maintaining an ideal body weight promote optimal wound healing. Such medications as​ anti-inflammatory drugs and antineoplastic agents may make a client more susceptible to infection due to suppression of the immune system. Taking pain medications does not increase risk of infection.)

A nurse is caring for an adolescent client with bipolar disorder. The nurse understands that this client may also have additional psychosocial alterations. Which condition is most likely complicating the client​'s ​diagnosis?

Substance abuse (The client with bipolar disorder may also experience substance abuse. While the client may also have anorexia​ nervosa, schizophrenia, or a personality​ disorder, the client is not at a greater risk for developing these conditions than any other client.)

A nurse is caring for a client with bipolar disorder with a depressive episode. The client tells the​ nurse, "I don​'t know why I even try anymore. I always fail at everything in my life. I should just give up." What aspect of the psychosocial history during the nursing exam is most important at this time for this​ client?

Suicide assessment (The nurse must assess the client for suicidal ideations. The client is expressing thoughts of​ worthlessness, which may indicate the client is suicidal. The other aspects are important for the nurse to assess during the psychosocial​ assessment; however, these are not the most important in this client at this time.)

A client with depression is prescribed an​ omega-3 fatty acid supplement. What should the nurse suggest when the client takes this​ supplement?

Take with orange juice (Omega-3 fatty acid supplements should be taken with orange juice to reduce the fishy aftertaste. The supplement SAMe should be taken 30 minutes before meals. There is no reason to withhold taking​ omega-3 fatty acid supplements before physical activity or with prescribed antidepressants.)

The nurse is planning care for a client diagnosed with situational depression. Which intervention is essential to include when planning​ care?

Teach assertiveness techniques. (When planning care for a client with situational​ depression, the nurse needs to teach the client assertiveness techniques. The client should be encouraged to express negative feelings while setting limits on negative talk. The nurse needs to provide positive reinforcement for accomplishments not negative reinforcements. The nurse also needs to engage the client in activities and not isolate.)

A client is seen in the clinic after being discharged from the hospital for treatment of a pressure ulcer. Which client outcomes demonstrate to the nurse that the treatment goals are being​ met?

The client and family demonstrate an understanding of preventive care measures. The client has enrolled in a smoking cessation program. The wound has decreased in size. (Regular evaluation of nursing and client goals are important. When the client and family demonstrate understanding of wound​ care, the wound has decreased in​ size, and the client has enrolled in a smoking cessation​ program, it indicates that nursing interventions and education have been effective. Greenish exudate indicates a possible​ infection; and the​ client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.)