BH ch 12, 13, 14, 15, 25 practice questions (week 4,5)

A nurse caring for a client diagnosed with major depressive disorder reads in the client's medical record, "This client shows vegetative signs of depression." Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.) a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

A, C, D, F Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self.

A client diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.) a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

a, b, c Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self.

Which suggestions are appropriate for the family of a client diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? (Select all that apply.) a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Supervise medication administration. e. Monitor the client's sleep patterns.

a, b, d, e A client with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure helps the client maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. The family should supervise medication administration to prevent deterioration to a full manic episode and because the client is at risk to omit medications.

A client tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? (Select all that apply.) a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

a, c Chronic low self-esteem and powerlessness are interwoven in the client's statements. No data support the other diagnoses.

A client being treated with paroxetine 50 mg po daily reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

a, d, e The client is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Serotonin syndrome may progress to a full medical emergency if not treated early. The client may have urinary retention, but frequency would not be expected.

A client diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The client twirls and shadow boxes. The client says gaily, "Do you like my scarves? Here they are my gift to you." How should the nurse document the client's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

a. euphoric The client has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the client's mood. Suspiciousness is not evident.

A client experiencing acute mania is dancing atop a pool table in the recreation room. The client waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, what is the nurse's first intervention? a. tell the client, "You need to be secluded." b. clear the room of all other clients. c. help the client down from the table. d. assemble a show of force.

b The client's behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other clients are out of the room, a plan for managing this client can be implemented. Threatening the client or assembling a show of force is likely to exacerbate the tension.

A client diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The client threatens to hit another client. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

c When the client is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the client, threaten the client with seclusion as punishment, and ask a rhetorical question.

A nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective? a. "I will need higher and higher doses of my medication as time goes on." b. "I need to store my medication in a cool dark place, such as the refrigerator." c. "Taking this medication regularly will reduce the severity of my symptoms." d. "If I run out or stop taking my medication, I will experience withdrawal symptoms."

c Antipsychotic drugs provide symptom control and allow most clients diagnosed with schizophrenia to live and be treated in the community. Dosing is individually determined. Antipsychotics are not addictive; however, they should be discontinued gradually to minimize a discontinuation syndrome.

A client diagnosed with schizophrenia begins a new prescription for ziprasidone. The client is 5'6'' and currently weighs 204 lbs. The client has dry flaky skin, headaches about twice a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the client's plan of care? a. Skin care techniques b. Scheduling a colonoscopy c. Weight management strategies d. Teaching to limit caffeine intake

c Ziprasidone is a second-generation antipsychotic medication. The incidence of weight gain, diabetes, and high cholesterol is high with second-generation antipsychotic medications. The client is overweight now, so weight management will be especially important. The other interventions may occur in time, but do not have the priority of weight management.

The plan of care for a client in the manic state of bipolar disorder should include which interventions? (Select all that apply.) a. Touch the client to provide reassurance. b. Invite the client to lead a community meeting. c. Provide a structured environment for the client. d. Ensure that the client's nutritional needs are met. e. Design activities that require the client's concentration.

c, d People with mania are hyperactive, grandiose, and distractible. It is most important to ensure the client receives adequate nutrition. Structure will support a safe environment. Touching the client may precipitate aggressive behavior. Leading a community meeting would be appropriate when the client's behavior is less grandiose. Activities that require concentration will produce frustration.

The admission note indicates a client diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.) a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

c, d, e Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this client's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

c. hyperactivity and no eating and sleeping Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the client. The other behaviors are less threatening to the client's life.

A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

c. poor judgment and hyperactivity Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

A client diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin b. clonidine c. risperidone d. carbamazepine

d Some clients diagnosed with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in clients with rapid cycling and in severely paranoid, angry manic clients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant.

A client diagnosed with acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement? a. direct the client to wear clothes at all times. b. ask if the client finds clothes bothersome. c. tell the client that others feel embarrassed. d. arrange for one-on-one supervision.

d A client who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the client to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the client is bothered by clothing serves no purpose. Telling the client that others are embarrassed will not make a difference to the client whose grasp of social behaviors is impaired by the illness.

A nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the nurse has not said anything funny. What is the nurse's most therapeutic response? a. "Why are you laughing?" b. "Please share the joke with me." c. "I don't think I said anything funny." d. "You're laughing. Tell me what's happening."

d The client is likely laughing in response to inner stimuli, such as hallucinations or fantasy. Focus on the hallucinatory clue (the client's laughter) and then elicit the client's observation. The incorrect options are less useful in eliciting a response: no joke may be involved, "why" questions are difficult to answer, and the client is probably not focusing on what the nurse said in the first place.

A client newly diagnosed with bipolar disorder is prescribed lithium. Which information from the client's medical history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

d The client with heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. None of the other options would present such a challenge.

A client diagnosed with schizophrenia says, "Contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident? a. Poverty of content b. Concrete thinking c. Neologisms d. Paranoia

d The client's unrealistic fear of harm indicates paranoia. Neologisms are invented words. Concrete thinking involves literal interpretation. Poverty of content refers to an inadequate fund of information.

A client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" What is the nurse's most therapeutic response? a. "Nothing you are saying is clear." b. "Your thoughts are very disconnected." c. "Try to organize your thoughts and then tell me again." d. "I am having difficulty understanding what you are saying."

d When a client's speech is loosely associated, confused, and disorganized, pretending to understand is useless. The nurse should tell the client that he or she is having difficulty understanding what the client is saying. If a theme is discernible, ask the client to talk about the theme. The incorrect options tend to place blame for the poor communication with the client. The correct response places the difficulty with the nurse rather than being accusatory.

A client diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a Although each of the nursing diagnoses listed is appropriate for a client having a manic episode, the priority lies with the client's physiological safety. Hyperactivity and poor judgment put the client at risk for injury.

While the exact cause of bipolar disorder has not been determined; however, what is consistent for most clients? a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

a The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

A client diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The client's use of "macnabs" should be documented using what term? a. a neologism. b. concrete thinking. c. thought insertion. d. an idea of reference.

a A neologism is a newly coined word having special meaning to the client. "Macnabs" is not a known common word. Concrete thinking refers to the inability to think abstractly. Thought insertion refers to thoughts of others are implanted in one's mind. Ideas of reference are a type of delusion in which trivial events are given personal significance.

The family of a client diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend? a. Psychoeducational b. Psychoanalytic c. Transactional d. Family

a A psychoeducational group explores the causes of schizophrenia, the role of medication, the importance of medication compliance, support for the ill member, and hints for living with a person with schizophrenia. Such a group can be of immeasurable practical assistance to the family. The other types of therapy do not focus on psychoeducation.

A client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely? a. An acute dystonic reaction b. Tardive dyskinesia c. Waxy flexibility d. Akathisia

a Acute dystonic reactions involve painful contractions of the tongue, face, neck, and back. Opisthotonos and oculogyric crisis may be observed. Dystonic reactions are considered emergencies requiring immediate intervention. Tardive dyskinesia involves involuntary spasmodic muscular contractions that involve the tongue, fingers, toes, neck, trunk, or pelvis. It appears after prolonged treatment. Waxy flexibility is a symptom seen in catatonic schizophrenia. Internal and external restlessness, pacing, and fidgeting are characteristics of akathisia.

Four new clients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these clients for safety. Which client diagnosis will need the most watchful supervision? a. bipolar I disorder. b. bipolar II disorder. c. dysthymic disorder. d. cyclothymic disorder.

a Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A client with bipolar I disorder is more unstable than a client diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

An acutely violent client diagnosed with schizophrenia received several doses of haloperidol. Two hours later the nurse notices the client's head rotated to one side in a stiffly fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated? a. Administer diphenhydramine 50 mg IM from the prn medication administration record. b. Reassure the client that the symptoms will subside. Practice relaxation exercises with the client. c. Give trihexyphenidyl 5 mg orally at the next regularly scheduled medication administration time. d. Administer atropine sulfate 2 mg subcut from the prn medication administration record.

a Diphenhydramine, trihexyphenidyl, benztropine, and other anticholinergic medications may be used to treat dystonias. Swallowing will be difficult or impossible; therefore, oral medication is not an option. Medication should be administered immediately, so the intramuscular route is best. In this case, the best option given is diphenhydramine.

A client diagnosed with bipolar disorder will be discharged tomorrow. The client is taking a mood stabilizing medication. What is the priority nursing intervention for the client as well as the client's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

a During the continuation phase of treatment for bipolar disorder, the physical needs of the client are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

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

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

What assessment findings mark the prodromal stage of schizophrenia? a. Withdrawal, misinterpreting, poor concentration, and preoccupation with religion b. Auditory hallucinations, ideas of reference, thought insertion, and broadcasting c. Stereotyped behavior, echopraxia, echolalia, and waxy flexibility d. Loose associations, concrete thinking, and echolalia neologisms

a Withdrawal, misinterpreting, poor concentration, and preoccupation with religion are prodromal symptoms, the symptoms that are present before the development of florid symptoms. The incorrect options each list the positive symptoms of schizophrenia that might be apparent during the acute stage of the illness.

A client diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the client. Which communication technique will be effective? a. Make observations. b. Ask the client direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the client to reduce guilt feelings.

a Making observations about neutral topics draws the client into the reality around him or her but places no burdensome expectations for answers on the client. Acceptance and support are shown by the nurse's presence. Direct questions may make the client feel that the encounter is an interrogation. Open-ended questions are preferable if the client is able to participate in dialogue. Platitudes are never acceptable. They minimize client feelings and can increase feelings of worthlessness.

The nurse receives a laboratory report indicating a client's serum level is 1 mEq/L. The client's last dose of lithium was 8 hours ago. What does this result indicate? a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

a Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.6 to 1.2 mEq/L.

A client is experiencing psychomotor agitation associated with major depressive disorder. Which observation presented by the client would the nurse associate with this symptom? a. pacing aimlessly around the room. b. asking the nurse to repeat instructions. c. reporting prickly skin sensations. d. demonstrating slowed verbal responses.

a Psychomotor agitation may be evidenced by constant pacing and wringing of hands. Slowed movements and responses are aspects of psychomotor retardation. Complaints of the unusual skin sensations may represent a delusion or hallucination. Asking the nurse to repeat instructions indicates difficulty with concentration.

Which documentation for a client diagnosed with major depressive disorder indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

a Sleeping 6 hours, participating with a group, and anticipating an event are all positive findings that suggest effectiveness of the plan of care. All the other options show at least one negative finding.

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

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

A health teaching plan for a client taking lithium should include which instructions? a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

A client diagnosed with bipolar disorder who takes lithium carbonate 300 mg three times daily reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with what? a. food. b. an antacid. c. an antiemetic. d. a large glass of juice.

a Some clients find that taking lithium with food diminishes nausea. The incorrect options are less helpful.

A client was diagnosed with seasonal affective disorder (SAD). During which month would this client's symptoms be most acute? a. January b. April c. June d. September

a The days are short in January, so the client would have the least exposure to sunlight. SAD is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.

Which documentation indicates that the treatment plan for a client diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

a The descriptors given indicate the client is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A client diagnosed with bipolar disorder commands other clients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other clients around." d. Honest feedback: "Your controlling behavior is annoying others."

a The distractibility characteristic of manic episodes can assist the nurse to direct the client toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the client or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.

When a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." What are common side effects the nurse should validate with the client? a. Sedation and muscle stiffness b. Sweating, nausea, and diarrhea c. Mild fever, sore throat, and skin rash d. Headache, watery eyes, and runny nose

a Typical antipsychotic drugs often produce sedation and extrapyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him or her feel like a "robot." The side effects mentioned in the other options are usually not associated with typical antipsychotic therapy or would not have the effect described by the client.

A client diagnosed with bipolar disorder is in the maintenance phase of treatment. The client asks, "Do I have to keep taking this lithium even though my mood is stable now?" What is the nurse's most appropriate response? a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Most clients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

b Clients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the client understand this need will promote medication adherence.

This nursing diagnosis applies to a client experiencing acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. What is an appropriate outcome for this client? a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

b High-calorie, high-protein food supplements will provide the additional calories needed to offset the client's extreme hyperactivity. Sitting with others or asking for assistance does not mean the client ate or drank. The other indicator is unrelated to the nursing diagnosis.

A client demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine. What is the rationale for the addition of olanzapine to the medication regimen? a. To minimize the side effects of lithium. b. To bring hyperactivity under rapid control. c. To enhance the antimanic actions of lithium. d. To be used for long-term control of hyperactivity.

b Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for long-term control.

A client diagnosed with major depressive disorder repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. What is the priority nursing diagnosis? a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b A client diagnosed with major depressive disorder who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

A client experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the client with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

b All the options are reasonable interventions for a client with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

A client says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report using what medical term? a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

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

What is the priority intervention for a client diagnosed with major depressive disorder and feelings of worthlessness? a. distracting the client from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the client to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

b Approximately two-thirds of people with depression contemplate suicide. Clients with depressive disorder who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the client diagnosed with depression may prevent a suicide attempt on the unit.

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

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

A nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon? a. Echolalia b. Catatonia c. Depersonalization d. Thought withdrawal

b Catatonia is the ability to hold distorted postures for extended periods of time, as though the client were molded in wax. Echolalia is a speech pattern. Depersonalization refers to a feeling state. Thought withdrawal refers to an alteration in thinking.

A nurse instructs a client taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of what? a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

b Clients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.

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

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

Which nursing diagnosis would most likely apply to a client diagnosed with major depressive disorder as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b Clients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for clients with depression. Defensive coping is more relevant for clients with mania. Fluid volume excess is less relevant for clients with mood disorders than is deficient fluid volume.

A client's care plan includes monitoring for auditory hallucinations. Which assessment findings suggest the client may be hallucinating? a. Detachment and overconfidence b. Darting eyes, tilted head, mumbling to self c. Euphoric mood, hyperactivity, distractibility d. Foot tapping and repeatedly writing the same phrase

b Clues to hallucinations include eyes looking around the room as though to find the speaker, tilting the head to one side as though listening intently, and grimacing, mumbling, or talking aloud as though responding conversationally to someone.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the client to identify and test negative thoughts

b During the immediate posttreatment period, the client is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the client in identifying and testing negative thoughts is inappropriate in the immediate posttreatment period because the client may be confused.

The spouse of a client diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of clients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among clients with bipolar disorder." c. "Clients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

b Evidence of genetic transmission is supported by lifetime prevalence statistics. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

A nurse leads a psychoeducational group about first-generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effect of these medications? a. Constipation b. Gynecomastia c. Visual changes d. Photosensitivity

b FGAs (first-generation antipsychotic) stimulate release of prolactin, which can result in gynecomastia (enlargement of the breasts) as well as other changes in sexual function. Men may experience disturbances in body image as a result of gynecomastia. Other side effects of FGAs may be disturbing to other aspects of the client's physical health but are not likely to bother body image.

A client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. The clinic nurse notes that the client grimaces and constantly smacks both lips. The client's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect? a. Agranulocytosis b. Tardive dyskinesia c. Tourette's syndrome d. Anticholinergic effects

b Fluphenazine decanoate is a first-generation antipsychotic medication. Tardive dyskinesia is a condition involving the face, trunk, and limbs that occurs more frequently with first- generation antipsychotics than second or third generation. Involuntary movements, such as tongue thrusting; licking; blowing; irregular movements of the arms, neck, and shoulders; rocking; hip jerks; and pelvic thrusts, are seen. These symptoms are frequently not reversible even when the drug is discontinued. The scenario does not present evidence consistent with the other disorders mentioned. Agranulocytosis is a blood disorder. Tourette's syndrome is a condition in which tics are present. Anticholinergic effects include dry mouth, blurred vision, flushing, constipation, and dry eyes.

During a psychiatric assessment, the nurse observes a client's facial expression is without emotion. The client says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the client's affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent.

b Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.

A client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication? a. Haloperidol b. Olanzapine c. Chlorpromazine d. Diphenhydramine

b Olanzapine is a second-generation atypical antipsychotic that targets both positive and negative symptoms of schizophrenia. Haloperidol and chlorpromazine are conventional antipsychotics that target only positive symptoms. Diphenhydramine is an antihistamine.

A client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The client's activities of daily living are severely compromised. What will be an appropriate outcome for this client? a. demonstrates increased interest in the environment by the end of week 1. b. performs self-care activities with coaching by the end of day 3. c. gradually takes the initiative for self-care by the end of week 2. d. accepts tube feeding without objection by day 2.

b Outcomes related to self-care deficit nursing diagnoses should deal with increasing ability to perform self-care tasks independently, such as feeding, bathing, dressing, and toileting. Performing the tasks with coaching by nursing staff denotes improvement over the complete inability to perform the tasks. The incorrect options are not directly related to self-care activities, difficult to measure, and unrelated to maintenance of nutrition.

A newly admitted client diagnosed with schizophrenia is hypervigilant and constantly scans the environment. The client states, "I saw two doctors talking in the hall. They were plotting to kill me." The nurse may correctly assess this behavior using which term? a. echolalia. b. paranoia c. a delusion of infidelity. d. an auditory hallucination.

b Paranoia is an irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you).; for example, when seeing two people talking, the individual assumes they are talking about him or her. The other terms do not correspond with the scenario.

A client has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today this client shouts, "They're all plotting to destroy me. Isn't that true?" what is the nurse's most therapeutic response? a. "Everyone here is trying to help you. No one wants to harm you." b. "Feeling that people want to destroy you must be very frightening." c. "That is not true. People here are trying to help you if you will let them." d. "Staff members are health care professionals who are qualified to help you."

b Resist focusing on content; instead, focus on the feelings the client is expressing. This strategy prevents arguing about the reality of delusional beliefs. Such arguments increase client anxiety and the tenacity with which the client holds to the delusion. The other options focus on content and provide opportunity for argument.

A client waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." What is the nurse's appropriate intervention? a. suggesting the client have a friend do the shopping and bring purchases to the unit. b. inviting the client to sit together and look at new fashion magazines. c. telling the client computer use is not allowed until self-control improves. d. asking whether the client has enough money to pay for the purchases.

b Situations such as this offer an opportunity to use the client's distractibility to staff's advantage. Clients become frustrated when staff deny requests that the client sees as entirely reasonable. Distracting the client can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the client's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the client has enough money would likely precipitate an angry response.

Transcranial Magnetic Stimulation (TCM) is scheduled for a client diagnosed with major depressive disorder. Which comment by the client indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure, so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

b TCM treatments take about 30 minutes. Treatments are usually 5 days a week. Clients are awake and alert during the procedure. After the procedure, clients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The client will be able to care for children.

A client diagnosed with schizophrenia says, "My co-workers are out to get me. I also saw two doctors plotting to kill me." How does this client perceive the environment? a. Disorganized b. Dangerous c. Supportive d. Bizarre

b The client sees the world as hostile and dangerous. This assessment is important because the nurse can be more effective by using empathy to respond to the client. Data are not present to support any of the other options.

A nurse taught a client about a tyramine-restricted diet. Which menu selection would the indicate the client understood the information? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

Which hallucination expressed by a client necessitates the nurse to implement safety measures? a. "I hear angels playing harps." b. "The voices say everyone is trying to kill me." c. "My dead father tells me I am a good person." d. "The voices talk only at night when I'm trying to sleep."

b The correct response indicates the client is experiencing paranoia. Paranoia often leads to fearfulness, and the client may attempt to strike out at others to protect self. The distracters are comforting hallucinations or do not indicate paranoia.

Outcome identification for the treatment plan of a client experiencing grandiose thinking associated with acute mania will focus on what? a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

b The desired outcome is that the client will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Clients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

At a unit meeting, the staff discusses decor for a special room for clients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

b The environment for a manic client should be as simple and non-stimulating as possible. Manic clients are highly sensitive to environmental distractions and stimulation.

A client diagnosed with bipolar disorder is prescribed lithium. The client telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" What advise will they give to the client? a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the client to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

b The symptoms described suggest lithium toxicity. The client should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the client should not drive and should be accompanied by another person. The incorrect options will not ameliorate the client's symptoms.

When a hyperactive client diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the client to act out feelings. b. Set limits on client behavior as necessary. c. Provide verbal instructions to the client to remain calm. d. Restrain the client to reduce hyperactivity and aggression.

b This intervention provides support through the nurse's presence and provides structure as necessary while the client's control is tenuous. Acting out may lead to loss of behavioral control. The client will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

A client demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this client. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and clients to discuss the behavior. d. Explain to the client that the behavior is unacceptable.

b When staff members are exhausted, the client has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a client experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Impaired mood regulation c. Sleep deprivation d. Chronic confusion e. Social isolation

b,c People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. The mood evidences euphoria and is labile. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

A client experiencing acute mania undresses in the group room and dances. How should the nurse intervene initially? a. quietly asking the client, "Why don't you put your clothes on?" b. firmly telling the client, "Stop dancing and put on your clothing." c. putting a blanket around the client and walking with the client to a quiet room. d. letting the client stay in the group room and moving the other clients to a different area.

c Clients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the client from public exposure by matter-of-factly covering the client and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

When counseling clients diagnosed with major depressive disorder, what therapy would an advanced practice nurse address the client's negative thought patterns? a. psychoanalytic b. desensitization c. cognitive-behavioral d. alternative and complementary

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

A nurse assesses a client who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

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

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

A client diagnosed with major depressive disorder began taking escitalopram 5 days ago. The client now says, "This medicine isn't working." What is the nurse's best intervention? a. discuss with the health care provider the need to increase the dose. b. reassure the client that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the client for symptoms of improvement.

c Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with clients.

The nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia? a. Auditory hallucinations b. Delusions of grandeur c. Poor personal hygiene d. Psychomotor agitation

c Negative symptoms include apathy, anhedonia, poor social functioning, and poverty of thought. Poor personal hygiene is an example of poor social functioning. The distractors are positive symptoms of schizophrenia. See relationship to audience response question.

A client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates catatonia. Which client needs are of priority importance? a. Self-esteem b. Psychosocial c. Physiological d. Self-actualization

c Physiological needs must be met to preserve life. A client with catatonia must be fed by hand or tube, toileted, given range-of-motion exercises, and so forth to preserve physiological integrity. Cattonia may also precipitate a risk for falls; therefore, safety is a concern. Higher level needs are of lesser concern.

A client diagnosed with schizophrenia has taken fluphenazine 5 mg po bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms? a. Neuroleptic malignant syndrome b. Hepatocellular effects c. Pseudoparkinsonism d. Akathisia

c Pseudoparkinsonism induced by antipsychotic medication mimics the symptoms of Parkinson's disease. It frequently appears within the first month of treatment and is more common with first-generation antipsychotic drugs. Hepatocellular effects would produce abnormal liver test results. Neuroleptic malignant syndrome is characterized by autonomic instability. Akathisia produces motor restlessness.

A client diagnosed with major depressive disorder received six electroconvulsive therapy (ECT) sessions and aggressive doses of antidepressant medication. The client owns a small business and was counseled not to make major decisions for a month. What is the correct rationale for this counseling? a. Antidepressant medications alter catecholamine levels, which impairs decision- making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with ECT. d. The client needs time to readjust to a pressured work schedule.

c Recent memory impairment and/or confusion may be present during and for a short time after ECT. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The client needing time to reorient to a pressured work schedule is less relevant than the correct rationale.

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family? a. Need to restrict sodium intake to 1 gram daily. b. Need to minimize exposure to bright sunlight. c. Importance of reporting increased suicidal thoughts. d. Importance of maintaining a tyramine-free diet.

c Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

A newly admitted client diagnosed with schizophrenia says, "The voices are bothering me. They yell and tell me I am bad. I have got to get away from them." Select the nurse's most helpful reply. a. "Do you hear the voices often?" b. "Do you have a plan for getting away from the voices?" c. "I'll stay with you. Focus on what we are talking about, not the voices. " d. "Forget the voices and ask some other clients to play cards with you."

c Staying with a distraught client who is hearing voices serves several purposes: ongoing observation, the opportunity to provide reality orientation, a means of helping dismiss the voices, the opportunity of forestalling an action that would result in self-injury, and general support to reduce anxiety. Asking if the client hears voices is not particularly relevant at this point. Asking if the client plans to "get away from the voices" is relevant for assessment purposes but is less helpful than offering to stay with the client while encouraging a focus on their discussion. Suggesting playing cards with other clients shifts responsibility for intervention from the nurse to the client and other clients.

A client being treated for depression has taken sertraline daily for a year. The client calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the client to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c The client has symptoms associated with abrupt withdrawal of the antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the client to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the client is experiencing.

Major depressive disorder resulted after a client's employment was terminated. The client now says to the nurse, "I'm not worth the time you spend with me. I am the most useless person in the world." Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

c The client's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a. clonazepam b. risperidone c. lamotrigine d. aripiprazole

c The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

Which dinner menu is best suited for a client with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

c These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive client could eat while in motion. The foods in the incorrect options cannot be eaten without utensils.

A client diagnosed with major depressive disorder is receiving imipramine 200 mg at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

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

A health care provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social function. The client is also overweight and hypertensive. Which drug should the nurse advocate? a. Clozapine b. Ziprasidone c. Olanzapine d. Aripiprazole

d Aripiprazole is a third-generation atypical antipsychotic effective against both positive and negative symptoms of schizophrenia. It causes little or no weight gain and no increase in glucose, high- or low-density lipoprotein cholesterol, or triglycerides, making it a reasonable choice for a client with obesity or heart disease. Clozapine may produce agranulocytosis, making it a poor choice as a first-line agent. Ziprasidone may prolong the QT interval, making it a poor choice for a client with cardiac disease. Olanzapine fosters weight gain.

A nurse leads a psychoeducational group about problem solving with six adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective? a. Suggest analogies that might apply to a common daily problem. b. Assign each participant a problem to solve independently and present to the group. c. Ask each client to read aloud a short segment from a book about problem solving. d. Invite participants to come up with solution to getting incorrect change for a purchase.

d Concrete thinking, an impaired ability to think abstractly resulting in interpreting or perceiving things in a literal manner, is evident in many clients diagnosed with schizophrenia. People who think concretely benefit from concrete situations during education. Finding a solution in order to get incorrect change for a purchase is an example of a concrete situation. Analogies require abstract thinking and insight. Independently solving a problem and presenting it to the group may be intimidating. All participants may or may not be literate.

A client diagnosed with schizophrenia says, "It's beat. Time to eat. No room for the cat." What type of verbalization is evident? a. Neologism b. Idea of reference c. Thought broadcasting d. Associative looseness

d Looseness of association refers to jumbled thoughts incoherently expressed to the listener. Neologisms are newly coined words. Ideas of reference are a type of delusion. Thought broadcasting is the belief that others can hear one's thoughts.

A client diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this client? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

A nurse worked with a client diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the client did not improve. The nurse is most at risk for what feelings? a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

d Nurses may have expectations for self and clients that are not wholly realistic, especially regarding the client's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with clients with depression because of the client's resistance. Guilt and despair might be seen when the nurse experiences the client's feelings because of empathy. Interest is possible, but not the most likely result.

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning? The client a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

d Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the client takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine- containing foods, not selenium, to produce dangerously high blood pressure.

A client diagnosed with schizophrenia has been stable for a year; however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says, "My computer is sending out infected radiation beams." The nurse can correctly assess this information as an indication of what? a. the need for psychoeducation. b. medication nonadherence. c. chronic deterioration. d. relapse.

d Signs of potential relapse include feeling tense, difficulty concentrating, trouble sleeping, increased withdrawal, and increased bizarre or magical thinking. Medication nonadherence may not be implicated. Relapse can occur even when the client is taking medication regularly. Psychoeducation is more effective when the client's symptoms are stable. Chronic deterioration is not the best explanation.

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

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

A disheveled client in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. What action will the nurse take? a. bring up the issue at the community meeting. b. calmly tell the client, "You must bathe daily." c. make observations about the client's poor personal hygiene. d. firmly and neutrally assist the client with showering.

d When clients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. The client needs assistance, not simply making an observation. Calmly telling the client to bathe daily and bringing up the issue at a community meeting are punitive.

A client with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the client's behavior? a. Educate the client about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the client's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The client may not be swallowing medications.

d. The client continues to exhibit manic symptoms. Nonadherence to the medication regime is a common problem for clients diagnosed with bipolar disorder. The lithium level should be approaching a therapeutic range after 7 days but may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the client does not address the problem.