Exam 2 NCLEX

A client in a manic state presents to the dayroom only partially dressed and is making sexual remarks and gestures toward the staff and other clients. Which is the initial nursing action? 1.Instruct the client to go back to his room. 2.Inform the client that such behavior will not be accepted. 3.Instruct the other clients to go to their rooms immediately. 4.Escort the client to his room to get appropriately dressed.

4.Escort the client to his room to get appropriately dressed.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1.Ask the client to leave the group for this session only. 2.Refer the client to another group that includes other manic clients. 3.Tell the client to stop monopolizing in a firm but compassionate manner. 4.Thank the client for the input, but inform the client that others now need a chance to contribute.

4.Thank the client for the input, but inform the client that others now need a chance to contribute.

The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client? 1.Drawing 2.Playing checkers 3.Painting by numbers 4.Putting a puzzle together

1.Drawing

The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue? 1."The last few weeks?" 2."You haven't had an appetite at all?" 3."Have patience; it will take time for your appetite to improve." 4."When the medication begins to work, your appetite will return."

2."You haven't had an appetite at all?"

The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? 1."You look lovely today." 2."You're wearing a new blouse." 3."Don't worry; everyone gets depressed once in a while." 4."You will feel better when your medication starts to work."

2."You're wearing a new blouse."

Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions? 1.Refuses to attend group therapy 2.Asks about how to get a will notarized 3.Argues with family members during visiting hours 4.Becomes easily agitated when roommate changes the television channel

2.Asks about how to get a will notarized

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? 1.Increase socialization of the client with peers. 2.Avoid using a whisper voice in front of the client. 3.Begin to educate the client about social supports in the community. 4.Have the client sign a release of information to appropriate parties for assessment purposes.

2.Avoid using a whisper voice in front of the client.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding the side and adverse effects of the medication? 1.Cardiovascular symptoms 2.Gastrointestinal dysfunctions 3.Problems with mouth dryness 4.Problems with excessive sweating

2.Gastrointestinal dysfunctions

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication? 1.In 2 months 2.In 2 to 3 weeks 3.During the first week 4.During the sixth week of administration

2.In 2 to 3 weeks

Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply. 1.Affects males more often than females 2.Is related to abnormal melatonin metabolism 3.Usually results in debilitating symptomatology 4.Improves during the spring and summer months 5.Is a result of alterations in the available amounts of sunlight 6.A craving for carbohydrates lessens during sunnier and spring months

2.Is related to abnormal melatonin metabolism 4.Improves during the spring and summer months 5.Is a result of alterations in the available amounts of sunlight 6.A craving for carbohydrates lessens during sunnier and spring months

A client reported to the nurse that he has been taking an extra dose of his tricyclic antidepressant for a week because he has been feeling more depressed than usual. Hearing this, the nurse knows which are the most appropriate actions to take? Select all that apply. 1.Tell the client that taking an extra dose is ok as long as it is not longer than 1 week. 2.Re-educate the client because tricyclic antidepressant overdoses can be life threatening. 3.Advise the client to take in more liquids while an extra dose is being taken because dry mouth is a side effect of this medication. 4.Tell the client to continue taking the extra dose; the client knows how he is feeling and can stop the extra dose when he is feeling more himself. 5.Inform the client that if he experiences any symptoms of dysrhythmias, dry mouth, confusion, agitation, or hallucinations, he should seek medical attention right away.

2.Re-educate the client because tricyclic antidepressant overdoses can be life threatening. 5.Inform the client that if he experiences any symptoms of dysrhythmias, dry mouth, confusion, agitation, or hallucinations, he should seek medical attention right away.

A client diagnosed with bipolar disorder is prescribed lithium carbonate. The nurse who administers the medication knows that lithium is used primarily to treat which condition? 1.Suicidal ideations 2.The manic phase of bipolar disease 3.Both depressive and manic episodes 4.The depressive phase of bipolar disease

2.The manic phase of bipolar disease

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1.Chess 2.Writing 3.Board games 4.Group exercise

2.Writing

A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1.Figs 2.Yogurt 3.Crackers 4.Aged cheese 5.Tossed salad 6.Oatmeal raisin cookies

3.Crackers 5.Tossed salad

The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT) to treat depression. Which medical diagnosis, if noted on the client's record, would indicate a need to contact the psychiatrist scheduled to perform the ECT? 1.Type 2 diabetes mellitus 2.Peripheral vascular disease 3.Recent myocardial infarction 4.Newly diagnosed hyperthyroidism

3.Recent myocardial infarction

A client is brought into the emergency department for suspected tricyclic antidepressant overdose. Place the actions that the nurse should take in order of priority. All options must be used. 1.Administer oxygen 2.Check and monitor vital signs. 3.Obtain an electrocardiogram. 4.Check airway and maintain patency. 5.Prepare gastric lavage with activated charcoal. 6.Prepare to administer prescribed medications.

4,1,2,3,5,6

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement? 1."I hope I am going to like my new counselor." 2."I sure hope I will still be productive at work." 3."I am going to keep a close check on any stress I have in my life." 4."I will take the medicine until I am sure I can handle my own problems."

4."I will take the medicine until I am sure I can handle my own problems."

Which statement made by a severely depressed client requires the nurse's immediate attention? 1."Feeling better really isn't important to me anymore." 2."No one can really understand what I've had to deal with." 3."I really don't like the way that new depression pill makes me feel." 4."I've not been the least bit interested in socializing since my divorce."

1."Feeling better really isn't important to me anymore."

A client diagnosed with depression is scheduled to receive 3 sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? 1.1 week after the 3rd treatment session 2.3 weeks after the treatment sessions begin 3.Midway between the 2nd and 3rd treatment session 4.8 weeks after the treatment sessions are completed

1.1 week after the 3rd treatment session

The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply. 1.Ask permission before touching the client. 2.Provide a warm, social approach to the client. 3.Eliminate all unnecessary physical contact with the client. 4.Defuse any anger or verbal attacks with a nondefensive stance. 5.Use simple and clear language when communicating with the client.

1.Ask permission before touching the client. 3.Eliminate all unnecessary physical contact with the client. 4.Defuse any anger or verbal attacks with a nondefensive stance. 5.Use simple and clear language when communicating with the client.

A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose? 1.On an empty stomach 2.At the same time each evening 3.Evenly spaced around the clock 4.As needed when the client complains of depression

2.At the same time each evening

A client with depression verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response? 1.Tell the client that this is not true, that we all have a purpose in life. 2.Identify recent behaviors or accomplishments that demonstrate the client's skills. 3.Reassure the client that the nurse knows how the client is feeling and that things will get better. 4.Remain with the client and sit in silence. This will encourage the client to verbalize feelings.

2.Identify recent behaviors or accomplishments that demonstrate the client's skills.

The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information should the nurse incorporate in the discussion? 1.Consume a low-fiber diet. 2.Increase fluids and bulk in the diet. 3.Rest if the heart begins to beat rapidly. 4.Walk if you have difficulty urinating because this is a normal side effect.

2.Increase fluids and bulk in the diet.

A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern? 1."Let's talk about the circumstances that caused you to lose your job." 2."There are homeless shelters available for people who are experiencing this exact situation." 3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" 4."Being homeless would allow us to admit you to the hospital so you will have a place to eat and sleep."

3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?"

A client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1.Client reports not going to work for the past week. 2.Client complains of not being able to "do anything" anymore. 3.Client arrives at the clinic neat and appropriate in appearance. 4.Client reports sleeping 12 hours per night and 3 to 4 hours during the day.

3.Client arrives at the clinic neat and appropriate in appearance.

The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? 1.Delay such planning until the client asks to participate in milieu. 2.Encourage the client to play solitaire while providing a deck of cards. 3.Provide a structured daily program of activities, and encourage the client to participate. 4.Offer the client a menu of daily activities and insist that the client participate in all of them.

3.Provide a structured daily program of activities, and encourage the client to participate.

The nurse is developing a plan of care for a client with depression who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client? 1.Fear 2.Anxiety 3.Risk for aspiration 4.Distorted body image

3.Risk for aspiration

A client diagnosed with bipolar mood disorder has been given a prescription for carbamazepine. The nurse teaching the client about medication side and adverse effects instructs the client to notify the primary health care provider if which symptom develops? 1.Nausea 2.Dizziness 3.Sore throat 4.Drowsiness

3.Sore throat

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1."Why do you believe your roommate would steal from you?" 2."I'll see if I can arrange for you to move in with a different roommate." 3."Tell me more about your belief that your roommate would steal from you." 4."I hear what you are saying, but I have no reason to believe your roommate steals."

4."I hear what you are saying, but I have no reason to believe your roommate steals."

The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion? 1."I know now that I can't be all things to all people all the time." 2."It is important for me to take my medications just as prescribed." 3."It's been good to learn better ways to deal with the stresses in my life." 4."I know that I won't become depressed again as long as I reduce my stressors."

4."I know that I won't become depressed again as long as I reduce my stressors."

The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? 1."I don't think I can do this on my own. I still need help coping with things. I know I need to keep working with staff, even now that I'm going home." 2."This has been the hardest thing I've ever had to deal with. I've made progress in learning how to communicate, especially with my family. It's hard to tell them when I need help." 3."I really tried to listen to what people said in the group sessions. Sometimes it was hard, but I think we really helped each other. I think I've learned it's all right to get disappointed sometimes." 4."I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."

4."I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."

During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? 1."Thank you, the perfume was a gift." 2."Your comment is really inappropriate." 3."Neither my hair nor my perfume is the focus of today's session." 4."The focus of today's session is on your issues, so let's get started."

4."The focus of today's session is on your issues, so let's get started."

A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? 1.Institute the unit's suicide precaution protocol. 2.Alert the client's psychiatrist of these changes immediately. 3.Notify the staff of these observations at today's team meeting. 4.Ask the client directly about the presence of any suicide-related thoughts.

4.Ask the client directly about the presence of any suicide-related thoughts.

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? 1.Restrict the client smoking for 12 hours. 2.Enforce nothing by mouth (NPO) status for 16 hours. 3.Limit the client's participation in unit activities for 24 hours. 4.Assure that an electrocardiogram is performed within 24 hours.

4.Assure that an electrocardiogram is performed within 24 hours.

Which is a primary behavior of a client diagnosed with antisocial personality disorder? 1.Frequently expresses suicidal ideations 2.Leaves the dayroom when anyone else enters 3.Will take personal items from other clients' rooms 4.Requires constant reassurance whenever required to make a decision

3.Will take personal items from other clients' rooms

A client diagnosed with depression is not eating adequately and at times even refuses to eat at all. What should the nurse plan to do to meet the client's nutritional needs? 1.Force foods and fluids. 2.Restrict social activities until food intake is increased. 3.Promptly provide snacks and meals when the client requests them. 4.Provide small, frequent meals that include the client's food preferences.

4.Provide small, frequent meals that include the client's food preferences.

A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1.Constipation 2.Seizure activity 3.Increased weight 4.Dizziness when getting upright

2.Seizure activity

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. 1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 3.Allow the client to eat alone in the room if the client requests to do so. 4.Offer small high-calorie, high-protein snacks during the day and evening. 5.Select the foods for the client to be sure that the client eats a balanced diet.

1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 4.Offer small high-calorie, high-protein snacks during the day and evening.

Which interventions should the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply. 1.Assisting the client to identify and test negative cognition 2.Assisting the client to participate in the treatment process 3.Assisting the client to develop alternative thinking patterns 4.Assisting the client to rehearse new cognitive and behavioral responses 5.Assisting the client with the administration of antidepressant medications 6.Assisting the client's family to participate in group therapy on a regular basis

1.Assisting the client to identify and test negative cognition 2.Assisting the client to participate in the treatment process 3.Assisting the client to develop alternative thinking patterns 4.Assisting the client to rehearse new cognitive and behavioral responses

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive

1.Avoidant

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? SATA. 1.Communicate expected behaviors to the client. 2.Ensure that the client knows that they are not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

1.Communicate expected behaviors to the client. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1.Have the client void. 2.Obtain an informed consent. 3.Administer tap water enemas. 4.Avoid discussing the procedure. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.

1.Have the client void. 2.Obtain an informed consent. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1.Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that they will not be able to attend any future group sessions

1.Setting limits on the client's behavior

A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? 1.Toxic 2.Normal 3.Slightly above normal 4.Excessively below normal

1.Toxic

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression? 1.The mother is caring for the infant in a loving manner. 2.The mother demonstrates an interest in the surroundings. 3.The mother constantly complains of tiredness and fatigue. 4.The mother looks forward to visits from the father of the newborn.

3.The mother constantly complains of tiredness and fatigue.

To create a safe environment for the client diagnosed with major depression with psychotic features, the nurse most importantly devises a plan of care that deals specifically with which problem? 1.Nutrition 2.Self-care needs 3.Disturbed thinking 4.Medication compliance

3.Disturbed thinking

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement? 1.Reassure the client that things will get better. 2.Tell the client that this is not true and that we all have a purpose in life. 3.Identify recent behaviors or accomplishments that demonstrate the client's skills. 4.Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3.Identify recent behaviors or accomplishments that demonstrate the client's skills.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan? 1.Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed

3.Increasing the level of suicide precautions

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? 1.Trusting the staff 2.Socializing with other clients at a holiday party 3.Making decisions about living arrangements after discharge 4.Identifying ways to minimize the tendency to be self-centered

3.Making decisions about living arrangements after discharge

A client diagnosed with depression has a prescription for sertraline. The nurse should withhold the medication and question the prescription if the client has a history of which disorder? 1.Diabetes mellitus 2.Myocardial infarction 3.Phenelzine sulfate use 4.Irritable bowel syndrome

3.Phenelzine sulfate use

The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1.The informed consent does not need to be obtained. 2.The informed consent should be obtained from the family. 3.The informed consent needs to be obtained from the client. 4.The primary health care provider will provide the informed consent.

3.The informed consent needs to be obtained from the client.

A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the most appropriate nursing response? 1."Next time, pick less dangerous and expensive ways to explode." 2."What can you do to stop your behavior when it gets to that point the next time?" 3."It's a good thing that you don't abuse substances, or you might be dead because of your recklessness." 4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1."Have you talked to your family about this?" 2."Everyone feels this way when they are depressed." 3."You will feel better once your medication begins to work." 4."You sound very upset. Are you thinking of hurting yourself?"

4."You sound very upset. Are you thinking of hurting yourself?"

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? 1.Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities until the client asks to participate in milieu 4.A structured program of activities in which the client can participate

4.A structured program of activities in which the client can participate

Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression? 1.Weigh the client 3 times per week before breakfast. 2.Explain to the client the importance of a good nutritional intake. 3.Report the nutritional concern to the psychiatrist, and obtain a nutritional consultation as soon as possible. 4.Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.

4.Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.

Which activity should the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation? 1.Playing checkers with members of the staff 2.Reading in a quiet, low-stimulus environment 3.Engaging in a card game with other clients on the unit 4.Attending a clay-molding class that is scheduled for today

4.Attending a clay-molding class that is scheduled for today

In formulating a discharge teaching plan, the nurse should include which precaution for a client with bipolar disorder who is prescribed lithium carbonate therapy? 1.Avoid soy sauce, wine, and aged cheese. 2.Have the blood lithium level checked every 2 weeks. 3.Take the medication only as prescribed to avoid becoming addicted. 4.Check with the psychiatrist before using any over-the-counter medications.

4.Check with the psychiatrist before using any over-the-counter medications.

A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? 1.Teach self-grooming skills. 2.Reward cleanliness with unit privileges. 3.Monitor the adequacy of the antipsychotic dosage. 4.Encourage frequent fluid intake and a high-fiber diet.

4.Encourage frequent fluid intake and a high-fiber diet.

A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor? 1.Continue to assess the client's behaviors and document clearly in the chart. 2.Report to the psychiatrist that the client is adapting to the unit and is feeling safe. 3.Notify the health team of these observations and alert them to the suspicion that the client is contemplating suicide. 4.Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.

4.Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.

A client diagnosed with depression and prescribed tranylcypromine sulfate has been instructed on the appropriate diet. The nurse determines that the client understands the diet if which foods are selected from the dietary menu? 1.Pickled herring, french fries, and milk 2.Pepperoni pizza, salad, and a cola drink 3.Roasted chicken, roasted potatoes, and beer 4.Fried haddock, baked potato, and a cola drink

4.Fried haddock, baked potato, and a cola drink

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1.Incessant talking and sexual innuendoes 2.Grandiose delusions and poor concentration 3.Outlandish behaviors and inappropriate dress 4.Nonstop physical activity and poor nutritional intake

4.Nonstop physical activity and poor nutritional intake

A client diagnosed with depression is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client's care plan should include which nursing intervention? 1.Obtain daily drug blood levels. 2.Provide the client a tyramine-free diet. 3.Assess the client for anticholinergic effects. 4.Obtain postural blood pressure prior to each medication administration.

4.Obtain postural blood pressure prior to each medication administration.

The primary health care provider is planning to prescribe a medication for a client with major depression. Which medication should the nurse expect to be prescribed? 1.Diazepam 2.Lorazepam 3.Phenobarbital 4.Paroxetine hydrochloride

4.Paroxetine hydrochloride

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client? 1.Isolating self 2.Inability to cope 3.Low self-esteem 4.Risk for self-harm

4.Risk for self-harm