Megan Mental Health Practice Unit 3 - CASPN Q4

A nurse on an inpatient unit is creating an educational presentation on bipolar disorder. Which of the following should the nurse plan to include in the presentation?

The prevalence, of bipolar disorder in adults is estimated at 2.8%. The nurse should identify that the prevalence of bipolar disorder in the United States among adults aged 18 or older is estimated to be at 2.8%, affecting, 2.9% of men and 2.8% of women.

A nurse on an inpatient mental health unit is reinforcing teaching to a newly licensed nurse about suicide prevention. Which of the following statements made by the newly licensed nurse indicates an undesrtanding of the information?

"All sharp object should be removed from the client's room." The nurse should identify that all items, including sharp objects or potential weapons, that could be potentially dangerous and used to complete a suicide attempt should be removed from the client's room.

A nurse is reinforcing discharge teaching with a client who as bipolar disorder and is to begin taking lithium. Which of the following instructions should the nurse include in the teacing?

"Avoid dieting" Lithium toxicity occurs when the level of lithium in the blood becomes too high. Crash dieting or fasting can lead to lithium toxicity because the sodium, electrolyte, and fluid balance would be altered, causing the blood levels of the lithium to rise.

A nurse is caring for a client who is threatening to commit suicide. Which of the following questions should the nurse ask?

"How will you carry out your plan?" This question will give the nurse important data, such as the client's planned method of self-harm.

A nurse at a primary care clinic is collecting data on a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?

"I can't get my mind to stop racing at night. I'm only sleeping a couple of hours." The nurse should identify that insomnia and hypersomnia can both be findings of depression.

A nurse is reinforcing teaching about valporate with a client who has bipolar disorder. Which of the following information should the nurse include in the teacing?

"Liver function tests must be monitored regularly." Hepatotoxicity is rare, but serious adverse affect; therefore, liver function tests must be performed.

A nurse is reinforcing education to a client about the possible causes of their depressed mood. Which of the following client statements indicates an understanding of the teaching?

"The stress from my new job could be the cause of my depressed mood." The nurse recognizes that the causes of mood disorders are an interplay of genetics, neurotransmitter dysfunction, brain dysfunction, neuroendocrine issues, environmental factors such as stress, and psychological factors such as sensitivity to stressors.

A nurse is reinforcing teaching with a client about a new prescription for lithium. Which of the following statements should the nurse include in the teaching?

"We will need to check your lithium levels in the next 3-5 days." Lithium is prescribed to treat bipolar disorder. The medication has a narrow therapeutic range and establishing a therapeutic lithium level is an essential component of care. It is recommended to check lithium levels within the first 5 days and beginning of treatment and possibly twice weekly until a maintenance dosage has been reached. Lithium levels are checked about every 3 months during maintenance therapy when lithium levels have stabilized.

A nurse is reinforcing teaching to a client who is to undergo transcranial magnetic stimulation (TMS) for depression. Which of the following information should the nurse provide?

"You may experience a mild headache following the procedure." The nurse should inform the client that it is common to experience a headache following the procedure. The headaches are usually mild and pass without incidence.

A nurse on the mental healthy unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

"You seem to be very upset about something. Tell me about it." This therapeutic response shows empathy for the client's feelings. The response is also open-ended, which allows the client the opportunity for further communication.

A nurse is reinforcing teaching to a client who is to undergo electroconvulsive therapy (ECT) for depression. Which of the following information should the nurse provide.

"Your provider will likely schedule you for several treatments over a period of weeks." The nurse should inform the client that, to be effective, ECT usually requires several treatments over a period of several weeks.

A nurse is caring for a client who is grieving and has experience sleep disturbances, weight loss, and often feels angry and irritable, The client also states that they feel depressed. Which of the following data is the nurse's priority to collect?

Ability to function Analysis of cues suggest the client has manifestations of prolonged grief disorder (PGD). Further assessment is needed to determine client's abiliity to function on a daily basis, Client safety and ability to care for themselves is the priority action for creating a plan of care.

A nurse is observing a newly licensed nurse providing care for a client who has bipolar disorder and is experiencing mania. The client continuously runs around the unit asking people to dance with her. Which of the following actions by newly licensed nurse is appropriate?

Asks the client to go outside with him and sit in the garden area It is appropriate to remove the client from the stimulating environment and to use instruction rather than bargaining to decrease activity level.

A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

Assist the client to practice social interaction with peers during a community meeting. Community meetings are an important part of the therapeutic milieu. Clients can practice social skills in a structured setting with other clients and a staff member present.

A nurse is caring for a client who has depression. Which of the following noninvasive treatments should the nurse recommend to the client?

Cognitive behavioral therapy The nurse should recommend cognitive behavioral therapy (CBT) as anon-invasive treatment for depression. CBT usually involves meeting with a trained therapist who empowers the client to change behavior by changing their thinking.

A nurse is caring for a client who has depression and states, "A government agency is attempting to capture me." The nurse should identify that the client is experiencing which of the following?

Delusions The nurse should identify that clients who have depression may exhibit manifestations of delusions or hallucinations. These findings are characteristic of psychotic depression.

A nurse is reviewing laboratory reports of a client who has bipolar disorder and notes a serum lithium level of 2.0 mEq/L. Which of the following actions should the nurse take?

Determine the client's vital signs The client's lithium level is indicative of lithium toxicity; therefore, the nurse should check the client's vital signs as well as his mental status and other possible manifestations of toxicity. The nurse should notify the provider immediately of the lab value and client status.

A nurse in a mental health clinic is taking a medical history on a client. The nurse should recognize that which of the following factors in the client's history increases their risk for mental illness?

Early exposure to violence The nurse should identify that early exposure to violence, abuse, and neglect in childhood can have long-term effects on clients, as shown in the Adverse Childhood Experiences Study by the CDC. The CDC has therefore advocated for early and intensive intervention when children display mood disorders related to trauma.

A nurse is assisting with the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse recommend to include?

Encourage short rest periods throughout the day The nurse should provide short rest periods throughout the day because the client might not aware of developing fatigue from hyperactivity. The client is at risk for injury without sufficient rest.

A nurse is creating a presentation about suicide prevention. When providing information about the prevalence of suicide, the nurse should include that a death occurs how often in the United States?

Every 11 min The nurse should identify that suicide is the tenth leading cause of death in the United States, accounting for one death every 11 min.

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

Grandiosity Grandiosity is inflated self-regard in a client who has bipolar disorder. Clients exaggerate their achievements and importance and believe they have exceptional powers.

A nurse is assisting in the care of a client who has bipolar disorder. The client states, "I feel like Superman. I can do anything. I can fly home today and then become a U.S. Senator." Which of the following findings should the nurse document the client is exhibiting?

Grandiosity Grandiosity refers to the client's believe that he has special abilities.

A nurse is assisting with the admission of a client to an acute mental healthy unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Initiate one-to-one nursing observation A recent suicide attempt indicates that this client is at greatest risk for another attempt; therefore, the first action the nurse should take is to initiate one-to-one nursing observation to provide continuous monitoring.

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse perform first?

Inspect the cuts for bleeding Inspection of the cuts is the first action the nurse should take when using the nursing process approach to client care.

A nurse is assisting with the admission of a client who has bipolar disorder and is experiencing an acute depressive episode. Which of the following prescriptions should the nurse anticipate receiving from the provider?

Lithium Carbonate Lithium carbonate, an antipsychotic and mood stabilizer, is the first-line treatment for clients who are experiencing an acute depressive episode of bipolar disorder.

A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide?

Loss of a job The nurse should identify that a risk factor for suicide is the loss of a job and therefore should be included in the presentation.

The nurse is assisting in the care of a client who is hyperactive, pacing down the hallway, and exhibiting poor concentration during group therapy. When collecting data, the nurse should identify that which of the following is characteristic of the client's manifestations?

Mania The nurse should identify that the client is exhibiting manifestations of mania, which include over-activity, overeating, overspending, poor sleeping habits, and speaking rapidly.

A public healthy nurse is applying for a grant related to suicide prevention. When describing social group s at highest risk, which of the following should the nurse include?

Native American The highest rates of suicide are among Native American and non-Hispanic White Americans, veterans, people in rural areas, and people who work in certain industries like mining and construction.

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. Which of the following is an appropriate food choice for this client?

Peanut butter sandwich A sandwich is an appropriate food choice for the client. Finger foods are a good choice for clients who are unable to focus on eating. Peanut butter is high in protein and calories, which are necessary for a client experiencing mania.

A nurse is caring for a client whose spouse died in a traumatic accident. Which of the following findings should the nurse manager identify as an indication of clinical depression.

Persistent dysphoria A client who is experiencing clinical depression can have persistent dysphoria.

A nurse is assisting in the care for a client who is exhibiting a depressed mood one week before the start of their menstrual cycle. When collecting data, the nurse should identify that the client is exhibiting manifestations consistent with which of the following disorders?

Premenstrual dysphoric disorder The nurse should identify that the depression experienced in premenstrual dysphoric disorder occurs in the week before a client menstruates.

A school nurse is assisting in creating a support group for students following the suicide of one of their peers. Which of the following interventions is the nurse providing?

Promoting connectedness By providing a support group to assist the students with the death of their peer, the nurse is promoting connectedness.

A nurse is reinforcing teaching with a client who is to start taking lithium carbonate. Which of the following dietary supplements should the nurse instruct the client to avoid?

St. John's Wort Taking St. John's Wort while taking lithium carbonate can lead to serotonin syndrome because both agents increase serotonin transmission.

A nurse is caring for a client who is experiencing mild depression and asks about herbal treatments. The nurse should identify that which of the following herbal treatments is used for depression?

St. John's Wort The nurse should explain to the client that St. John's Wort is an herbal supplement that is used as an alternate therapy for depression. The supplement should not be used in addition to an SSRI medication as this can lead to serotonin syndrome.

A nurse is assisting with the development of a community health education class about suicide prevention. Which of the following information should the nurse identify as risk factors for suicide? (Select all that apply)

Substance use disorder- Clients who have a substance use disorder are at a higher risk for suicide Age greater than 45- The rate of suicide increases with age and peaks after the age of 45 Schizophrenia- Clients who have schizophrenia are at high risk for suicide

A nurse is reinforcing teaching with a client who is to start taking lithium for bipolar disorder. Which of the following instructions should the nurse include?

Take lithium with meals or a glass of milk The client should take the medication with meals or milk to decrease gastric ditress

A nurse is caring for a school-aged client. Complete the following sentence by using the lists of options.

The client is at highest risk for developing disruptive mood dysregulation disorder as evidenced by the client's recurrent outbursts out of proportion to the situation. The nurse should gather data to compare client findings to evidence-based resources and standards of care. The client is at risk for developing DMDD due to severe, recurrent outbursts out of proportion to the situation. Other diagnostic criteria for DMDD include onset of symptoms before the age of 10, but diagnosis is made between the ages of 6 and 18 years of age. Symptoms must be present for 12 months or more, and symptoms should be present in at least two settings.

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

The client paces in the hallway during the day and most of the night When using Maslow's hierarchy of needs, the nurse determines that the priority findings are the client's physiological need for rest and food. Nonstop activity is an emergency situation for a client who has mania, since the client might go for long periods without eating or sleeping.

A nurse is an acute mental health unit is assisting with the admission of a client who has bipolar disorder. Which of the following findings indicates that the client is experiencing acute mania?

The client responds to questions with disorganized speech Clients who are experiencing acute mania exhibit disorganized speech, such as a flight of ideas.

A nurse is caring for a client who is 2 weeks postpartum. The client tells the nurse, "I feel really down and sad lately. I have no energy and I feel like I'm going to cry." Which of the following actions should the nurse take first?

Use a postpartum depression-screening tool with the client The first action the nurse should take using the nursing process is to collect data from the client in order to determine the extent of the client's feelings of depression. The majority of postpartum lients express fatigue and some level of sadness due to hormonal changes and stress. A postpartum screening tool can detect postpartum depression, which can be a severe risk to the health of both the client and her newborn.

A nurse is reinforcing reaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?

Vomiting and diarrhea Early manifestations of lithium toxicity include diarrhea, lethargy, impaired coordination, muscle weakness, nausea or vomiting, slurred speech, and trembling. If the client experiences vomiting and diarrhea, the client should omit the next dose of lithium and call the provider.

A nurse is precepting a newly hired nurse. The newly hired nurse asks, "Why is it important for me to attend a training on compassion fatigue and burnout?" Which of the following responses should the precepting nurse makes?

"Compassion fatigue can occur because nurses often experience trauma. We must learn to prioritize our self-care." Compassion fatigue (CF) can be experienced by nurses due to occupational stress and exposure to trauma, such as the death of clients. Education about CF and best practices, such as self-care practice, are important strategies to reduce CF.

A nurse is caring for a postpartum client and her newborn. The client asks the nurse to feed the newborn. Which of the following responses should the nurse make?

"Feeding an infant can feel a little intimidating at first, but I'll stay with you to help." The nurse, while recognizing and accepting this client's apprehension, offers assistance and her presence, with the intention of boosting her confidence and also collecting data regarding the client's mood.

A nurse in a community clinic is speaking to a parent who expresses concern for her adolescent son. Which of the following statements by the mother should indicate to the nurse that adolescent is at a risk for suicide?

"His basketball coach committed suicide last month." Adolescents are at risk for a "copycat" suicide if a peer or a significant role model has recently committed suicide. Adolescents often act impulsively and can be easily frustrated. The fact that an admired person committed suicide is a stressor that could put the adolescent at risk for suicide.

A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?

"I will help you sit up and get your slippers on." This statement shows caring by the nurse and provides for collaboration with the client, which is an appropriate intervention for a client who has depression. The nurse should give step-by-step instructions and encourage the client to perform ADLs.

A nurse is assisting with a conflict-resolution group for adolescent clients in community clinic facility. Which of the following clients should the nurse identify as being the highest risk for a suicide attempt?

A client who attempted suicide the previous year Suicide is the second-leading cause of death among adolescents. The nurse must listen carefully to any young person who speaks about harming herself or others. The highest risk for a suicide attempt is a previous suicide attempt; therefore, according to evidence-based practice, collecting data regarding a suicide attempt for this client should be nurse's priority.

A nurse is reviewing the medical record of a client who attempted suicide. Which of the following findings should the nurse identify as risk factors for suicide? (Select all that apply)

Diagnosis of major depressive disorder- Co-occuring mental healthy disorders, which can interfere with coping skills, can increase a client's suicide risk Unemployment- Unemployment, which can lead to feeling of hopelessness and financial problems, can increase a client's suicide risk Access to firearms- Access to firearms increases a client's risk for suicide due to the availability of a weapon

A school nurse is assisting in the planning a presentation on identifying potential warning signs of suicide for high school students. Which of the following examples of behaviors should the nurse include in the presentation?

Displaying extreme mood swings The nurse should include in the presentation that sudden and extreme mood swings might be a warning sign that a student is considering suicide.

A nurse is reinforcing teaching with a group of adolescents regarding identifying behavioral indicators of depression. Which of the following manifestations should the nurse include? (Select all that apply)

Irritability- A manifestation of depression in adolescents is an irritability and bouts of anger Decreased energy- The adolescent who has depression might begin to have difficulty getting through daily tasks due to loss of energy Isolation- The adolescent who is depressed often withdraws from family and peers and might become isolated

A nurse is caring for a client who is in the acute manic phase of bipolar disorder. Which of the following actitivies is appropriate for the nurse to suggest to the client?

Walking with the nurse on the grounds of the facility Gross motor and physical activities provide clients who are manic with an opportunity to expend their excess energy. Walking with the nurse allows for a safe, controlled activity. The nurse will be ready available to divert the client's attention from distractions.

A nurse on a behavioral health unit is assisting with the care of a client. Complete the following sentence by using the lists of options.

When using Maslow's hieracrhy of needs, the nurse determines that the priority findings is physical exhaustion because of the client's constant motion, risk for inadequate nutritional intake, and altered judgment which in a manic state.

A nurse is reviewing lab results for a client who is receiving lithium carbonate. The client's blood lithium level is 1.8 mEq/L. Which of the following actions should the nurse take?

Withhold the medication A blood lithium level greater than 1.5 mEq/L indicates toxicity; therefore, the medication should be withheld and the provider notified.

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take?

Withhold the medication Early signs of lithium toxicity can be detected by assessing for nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, and fine hand tremors. The medication should be withheld for further evaluation.

A nurse in an acute care mental healthy facility is caring for a client who has depression and has performed no ADLs since admission 3 days ago. The nurse observes that the client is now wearing clean clothes and has combed her hair. Which of the following is an appropriate response by the nurse?

"I see that you have on clean clothes and have combed your hair." This comment makes an observation, providing recognition of the client's behavior without making a value judgment of offering approval. This is a therapeutic communication technique.

A nurse is caring for a client who has returned from a bereavement support group. Which of the following client statements demonstrates that the client is meeting the planned outcomes of treatment?

"I will take the kids to the ocean. We had great times there as a family, and it's time for more memories." Accepting the death of the loved one and the loss is evidence that bereavement care and therapy are working.

A nurse is caring for a client who is 1 day postpartum. The client tells the nurse, "The baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse make?

"I'll sit here while you feed him and we'll check out his breathing." Telling the client that the nurse will stay with the client and will help check the newborn's breathing demonstrates caring about the client's feelings. The nurse can then collect data regarding the newborn and can intervene as needed.

A nurse is assisting in the care of a client who has a persistent depressive disorder. When reinforcing education to the client about their illness, which of the following statements should the nurse make?

"Persistent depressive disorder is a mild chrnoic form of depression." The nurse recognizes that persistent depressive disorder is also know as dysthymia and is characterized as a less severe for of depression.

A client who is depressed and has attempted suicide tells the nurse, "Ishould have died because I am totally worthless." Which of the following responses should the nurse make?

"You've been feeling that your life has no meaning." This open-ended statement uses the communication technique of showing empathy and addresses the client's feeling of worthlessness. This therapeutic response communicates to the client that the nurse was listening, and it will encourage the client to talk further about personal feelings.

A nurse is collecting data from a group of clients who have anxiety disorders and have prescriptions for various psychotropic medications. The nurse should recognize which of the following clients as having an increased risk for suicide?

A client who has an obsessive-compulsive disorder and take fluoxetine. Fluoxetine, a SSRI antidepressant, is prescribed for depression and well as for a number of anxiety disorders. An adverse effect of fluoxetine is that it can cause increased risk for suicide in both children and adults. The nurse should monitor for suicide risk when collecting data for this client.

A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take?

Reinforce how to use assertive communication techniques. The nurse should reinforce how the client can use assertive communication techniques when interacting with others. This can improve the client's self-esteem and increase a sense of control.

A nurse is collecting data from a newly-admitted client who has bipolar disorder and is displaying manic behavior. Which of the following findings should the nurse expect? (Select all that apply)

Talking in rapid, continuous speech- Clients experiencing a manic state may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. They often demonstrate boundless enthusiasm and treat others with confidential friendliness. DIGFAST is a way to recall and apply manifestations of manic episodes: delusions, impulsivity, grandiose thoughts, flight of ideas, accelerated speech, sleeplessness, and talkativeness. Interacting with others in a flirtatious way- A client who is experiencing a manic episode displays attention-seeking behavior through means of flashy attire and makeup, or through flirtatious, inappropriate behavior toward others. This interaction is a manifestation of the client's lack of impulse control. Reports spending large sums of money- In the manic state, a person may give away money, prized possessions, and expensive gifts. Intervention often is needed to prevent financial collapse. Exhibiting clang associations- In the manic state, clients who have bipolar disorder exhibit clang associations. These are the stringing together of words because of their rhyming sounds, without regard to their meaning.