Mental Health unit 2

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should the priority nursing action, and why?

1-1 monitoring

The nurse is prioritizing nursing diagnoses in the plan of care for a patient experiencing a manic episode. Number the diagnoses in order of the appropriate priority. a. Disturbed sleep pattern evidenced by sleeping only 4 to 5 hours per night b. Risk for injury related to manic hyperactivity c. Impaired social interaction evidenced by manipulation of others d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor

1= B, 2= D, 3= a, 4= C

A client is prescribed phenelzine. What statements by the client should indicate to the nurse that discharge teaching about this medication has been successful? SATA A. I'll have to let my surgeon know about this med before I have my cholecystectomy B. Guess I will have to give up my glass of red wine with dinner. C. I'll have to be very careful about reading food and medication labels. D. I'm going to miss my caffeinated coffee in the morning E. I'll be sure not to stop this medication abruptly.

A. I'll have to let my surgeon know about this med before I have my cholecystectomy B. Guess I will have to give up my glass of red wine with dinner. C. I'll have to be very careful about reading food and medication labels. E. I'll be sure not to stop this medication abruptly.

A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide? A. The client has begun playing basketball with several other clients during the past month B. The client identifies with problems expressed by other clients C. The client's behavior has become impulsive in the past few weeks D. The client states she wants to go home to be with her children and partner

C. The client's behavior has become impulsive in the past few weeks

A client has been diagnosed with major depression. The psychiatrist prescribed Paroxetine (Paxil). Which of the following medication information should the nurse include in discharge teaching? A. Do not eat chocolate while taking this medication B. The medication may cause priapism C. The medication should not be discontinued abruptly D. The medication may cause photosensitivity

C. The medication should not be discontinued abruptly

A nurse is planning care for a client how has dependent personality disorder. Which of the following actions should the nurse plan to take? a. Monitor the client closely to prevent self-mutilation b. Set limits to prevent exploitation of other clients c. Discourage flamboyant or seductive behaviors D. Give positive feedback when client is assertive with staff or clients

D. Give positive feedback when client is assertive with staff or clients

A psychiatrist prescribes a MAOI for a client. Which foods should the nurse teach the client to avoid

Tyramine containing foods: smoke meats wine aged cheeses ect

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements is expected from a client who has this type of personality disorder? a. "I'm scared that you're going to leave me." b. "I'll go to through therapy if you'll let me smoke." c. "I need to feel that everyone admires me." d. "I sometimes feel better if I cut myself."

a. "I'm scared that you're going to leave me."

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected? a. "it's not my fault." b. "I'm too ashamed to talk about it." c. "I just don't remember doing it." d. "I'm really sorry about all the people I've hurt."

a. "it's not my fault."

The physician orders lithium carbonate 600 mg tid for a client newly diagnosed with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. What is the therapeutic range for acute mania? a. 0.5 to 1.5 mEq/L b. 10 to 15 mEq/L c. 0.5 to 1 mEq/L d. 5 to 10 mEq/L

a. 0.5 to 1.5 mEq/L

A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for this client? a. A private room in a quite location on the unit b. A semi-private room with a roommate who has a similar diagnosis c. A private room close to the nursing stating d. A seclusion room until the client's activity level becomes more subdued

a. A private room in a quite location on the unit

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client? a. Adopt a neutral attitude when providing care b. Disclose some personal information to the client to demonstrate approachability c. Wait for the client to initiate interaction d. Approach the client frequently throughout the day for brief interactions

a. Adopt a neutral attitude when providing care

A patient with depression asks the nurse, "Why would they be checking my thyroid function when I clearly have depression and I'm not overweight?" Which of these is an accurate response? a. An underactive thyroid gland can manifest as depression. b. Depression has been proven to be a hormonal illness. c. Thyroid hormone replacement is a first-line treatment for most people with depression. d. Abnormal thyroid function predicts positive response to antidepressant medication.

a. An underactive thyroid gland can manifest as depression.

A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take? a. Ask the client if she has a plan to commit suicide b. Recognize the attempt at manipulation and escort the client back to her activity c. Assist the client to her room and allow her to rest before resuming activity d. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

a. Ask the client if she has a plan to commit suicide

According to Margaret Mahler, predisposition to BPD occurs when developmental tasks go unfulfilled in which of the following phases? a. Autistic phase, during which the child's needs for security and comfort go unfulfilled b. Symbiotic phase, during which the child fails to bond with the mother c. Differentiation phase, during which the child fails to recognize a separateness between self and mother d. Rapprochement phase, during which the mother withdraws emotional support in response to the child's increasing independence

a. Autistic phase, during which the child's needs for security and comfort go unfulfilled

A client is unwilling to go to his church because his ex-girlfriend does 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 address which personality disorder? a. Avoidant b. Borderline c. Schizotypal d. Obsessive-compulsive

a. Avoidant

A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? Select all that apply. a. Believes that others are deceiving him b. Desires to be the center of attention c. Views himself as inferior to others d. Demonstrates a grandiose sense of self-importance e. Persistently holds onto a grudge

a. Believes that others are deceiving him e. Persistently holds onto a grudge

A nurse is caring for a client who has paranoid personality disorder. Which of the following findings should the nurse expect? SATA a. Believes that others are deceiving him b. Desires to be the center of attention c. Views himself as inferior to others d. Demonstrates a grandiose sense of self-importance e. Persistently holds onto grudges

a. Believes that others are deceiving him e. Persistently holds onto grudges

A client is considering ECT and asks for some information. Which statements are accurate? SATA a. Can be used in patients who have not responded to antidepressant therapy b. One treatment is usually all that is needed c. A long-acting anesthetic agent is given d. Side effects may include headache, some confusion or memory loss

a. Can be used in patients who have not responded to antidepressant therapy d. Side effects may include headache, some confusion or memory loss

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

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

A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client? a. Dialectical behavior therapy b. Behavioral contract c. Bibliotherapy d. Safety plan

a. Dialectical behavior therapy

A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? a. Do not skimp on dietary sodium intake b. Have serum lithium levels checked every 6 months c. Limit fluid intake to 1000 mL of fluid per day d. Adjust the dose if you feel out of control

a. Do not skimp on dietary sodium intake

Immediately after electroconvulsive therapy, in which position should a nurse place the client? a. On his or her side to prevent aspiration b. B. in high flowers position to promote consciousness c. In Trendelenburg's position to promote blood flow to vital organs d. In probe position to prevent airway blockage.

a. On his or her side to prevent aspiration

Demitrius informs the nurse that his doctor is considering ECT and asks for some information about the procedure. Which of the following are accurate statements that the nurse can share with this patient? (Select all that apply.) a. ECT is typically used to treat patients who have not responded to antidepressant therapy. b. A long-acting anesthetic agent is given to the patient the morning of the treatment. c. One treatment is usually all that is needed to relieve depression. d. Side effects may include headache and some confusion or memory loss.

a. ECT is typically used to treat patients who have not responded to antidepressant therapy. d. Side effects may include headache and some confusion or memory loss.

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take? a. Explain that antidepressants often take several weeks to be fully effective b. Speak to the provider about adding an MAOI to the current medication regimen c. Tell the client the provider needs to change citalopram to a different medication. d. Recommend a sleep study be done on the client.

a. Explain that antidepressants often take several weeks to be fully effective

The goal of cognitive therapy with depressed clients is to: a. Identify and change dysfunctional patterns of thinking. b. Resolve the symptoms and initiate or restore adaptive family functioning. c. Alter the neurotransmitters that are creating the depressed mood. d. Provide feedback from peers who are having similar experiences.

a. Identify and change dysfunctional patterns of thinking.

What is the goal of cognitive therapy in depression? a. Identify and change patterns of thinking b. Alter the neurotransmitters that are creating the depressed mood c. Resolve the symptoms and initiate or restore adaptive family functioning d. Provide feedback from peers who are having similar experiences.

a. Identify and change patterns of thinking

A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take? a. Inspect the client's personal belongings b. Place metal utensils on the client's meal tray c. Assign the client to a private room d. Tuck bedcovers over client's hands and arms.

a. Inspect the client's personal belongings

Jack is a new patient on the psychiatric unit with a diagnosis of antisocial personality disorder. Which of the following characteristics would you expect to assess in Jack? a. Lack of guilt for wrongdoing b. Insight into his own behavior c. Ability to learn from past experiences d. Compliance with authority

a. Lack of guilt for wrongdoing

A patient expresses interest in alternative treatments for depression with seasonal variations and asks the nurse about light therapy. Which of the following are evidence-based teaching points that the nurse may share with the patient? (Select all that apply.) a. Light therapy has demonstrated effectiveness that is comparable to antidepressants. b. Light therapy should be used regularly until the season changes. c. Light therapy should only be used when ECT has proven to be ineffective. d. Side effects such as headache, nausea, or agitation, when they occur, are usually mild and transient. e. Light therapy can cause sedation so the best time to use it is before bedtime.

a. Light therapy has demonstrated effectiveness that is comparable to antidepressants. b. Light therapy should be used regularly until the season changes. d. Side effects such as headache, nausea, or agitation, when they occur, are usually mild and transient.

Light therapy is an alternative tx for depression with seasonal variations. Which points are EVB? SATA a. Light therapy is comparable to antidepressants b. Should be used regularly until the season changes c. SE of headache, nausea, or agitation are usually mild and transient d. Can cause sedation so the best time to use it is before bedtime.

a. Light therapy is comparable to antidepressants b. Should be used regularly until the season changes c. SE of headache, nausea, or agitation are usually mild and transient

Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? (Select all that apply.) a. Olanzapine (Zyprexa) b. Oxycodone (Oxycontin) c. Carbamazepine (Tegretol) d. Gabapentin (Neurontin) e. Tranylcypromine (Parnate)

a. Olanzapine (Zyprexa) c. Carbamazepine (Tegretol) d. Gabapentin (Neurontin)

Which of the following behavioral patterns is characteristic of individuals with narcissistic personality disorder? a. Overly self-centered and exploitative of others b. Suspicious and mistrustful of others c. Rule conscious and disapproving of change d. Anxious and socially isolated

a. Overly self-centered and exploitative of others

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have BPD? (SATA) a. Paroxetine b. Lithium c. Donepezil d. Valproate e. Carbamazepine

a. Paroxetine b. Lithium d. Valproate e. Carbamazepine

A nurse is reviewing medication records for several clients who have bipolar disorder. The nurse should recognize that which of the following medications are used to treat clients who have bipolar disorder? (SATA) a. Paroxetine b. Lithium c. Donepezil d. Valproate e. Carbamazepine

a. Paroxetine b. Lithium d. Valproate e. Carbamazepine

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? a. Placing the client on one-to-one observation b. Assisting the client to perform ADLs c. Encouraging the client to participate in counseling d. Teaching the client about medication adverse effects

a. Placing the client on one-to-one observation

A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority for the nurse to make? a. Promote appropriate behavior during group therapy sessions b. Encourage client input in the treatment plan c. Communicate with the client using concrete language d. Demonstrate assertive behavior

a. Promote appropriate behavior during group therapy sessions

A nurse in an acute mental health facility is creating a plan of care of a new client who has histrionic personality disorder. Which of the following is the priority intervention for nurse to make? a. Promote appropriate behavior during group therapy sessions b. Encourage client input in the treatment plan c. Communicate with the client using concrete language d. Demonstrate assertive behavior

a. Promote appropriate behavior during group therapy sessions

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations which is the nurses' immediate priority of care? a. Provide safety for the client and other clients on the unit b. Provide the clients on the unit with a sense of comfort and security c. Assist the staff in caring for the client in a controlled environment d. Offer the client a less stimulating area in which to calm down and gain control

a. Provide safety for the client and other clients on the unit

Kim, a patient diagnosed with BPD, manipulates the staff in an effort to fulfill her own desires. All of the following may be examples of manipulative behaviors in the borderline client except: a. Refusal to stay in room alone, stating, "It's so lonely." b. Asking the nurse for cigarettes after 30 minutes, knowing that the assigned nurse has explained she must wait 1 hour. c. Stating to the nurse, "I really like having you for my nurse. You're the best one around here." d. Cutting arms with razor blade after discussing discharge plans with physician.

a. Refusal to stay in room alone, stating, "It's so lonely."

In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? a. Risk for injury related to excessive hyperactivity b. Disturbed sleep pattern related to manic hyperactivity c. Imbalance nutrition, less than body requirements, related to inadequate intake d. Situational low self-esteem related to embarrassment secondary to high-risk behaviors

a. Risk for injury related to excessive hyperactivity

A client diagnosed with a personality disorder is cold, aloof, and avoids others on the unit. The nurse recognizes that this behavior is symptomatic of which personality disorder? a. Schizoid personality disorder b. Dependent personality disorder c. Borderline personality disorder d. Antisocial personality disorder

a. Schizoid personality disorder

A client with Major depressive disorder was admitted to the unit. Which manifestations can be present? SATA a. Slumped posture b. Delusional thinking c. Feelings of despair d. Feels best early in the morning and worse as the day progresses

a. Slumped posture b. Delusional thinking c. Feelings of despair

A patient has just been admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder. Which of the following manifestations may be apparent in a patient with this diagnosis? (Select all that apply.) a. Slumped posture b. Delusional thinking c. Feelings of despair d. Feels best early in the morning and worse as the day progresses e. Anorexia

a. Slumped posture b. Delusional thinking c. Feelings of despair e. Anorexia

SJ has MDD and repeatedly makes negative statements about herself. Which interventions increase self-esteem? SATA a. Teach assertive communication skills b. Tell her you will not talk to her when she is negative about herself c. Make observations to SJ when she completes a goal or task d. Spend time with SJ using a nonjudgmental, accepting approach

a. Teach assertive communication skills c. Make observations to SJ when she completes a goal or task d. Spend time with SJ using a nonjudgmental, accepting approach

Shondra is admitted to the hospital with major depressive disorder and repeatedly makes negative statements about herself. Which of the following interventions is identified as an approach that promotes positive self-esteem in the patient? (Select all that apply.) a. Teach assertive communication skills. b. Make observations to Shondra when she completes a goal or task. c. Instruct Shondra that you will not talk with her unless she stops talking negatively about herself. d. Offer to spend time with Shondra using a nonjudgmental, accepting approach.

a. Teach assertive communication skills. b. Make observations to Shondra when she completes a goal or task d. Offer to spend time with Shondra using a nonjudgmental, accepting approach.

A nurse is teaching a client who has depression about ECT. Which of the following information should the nurse include in the teaching? a. Temporary memory loss is the most common adverse effect of ECT b. Medications are given to prevent seizure activity during ECT c. The greatest risk of ECT is brain damage d. ECT is effective in the treatment of substance use disorders.

a. Temporary memory loss is the most common adverse effect of ECT

A nurse is providing discharge teaching to a client who has BPD and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity? a. The client runs 2 miles outdoors every afternoon b. The client drinks 2 liters of liquid per day c. The client eats 2 to 3 grams of sodium containing food daily d. The clients eats foods high in tyramine

a. The client runs 2 miles outdoors every afternoon

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy(ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make? a. The main side effects are temporary and may include mild confusion, a headache, and short-term memory loss b. Most clients have no adverse effects to this treatment, but muscle cramping may result from the induced seizure. c. Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen. d. The most common side effects are directly related to the anesthesia.

a. The main side effects are temporary and may include mild confusion, a headache, and short-term memory loss

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? a. setting limits on the clients behavior b. asking the client to leave the group session c. asking another nurse to escort the client out of the group session d. telling the client that they will not be able to attend any future group sessions

a. setting limits on the clients behavior

A nurse is caring for a client who has bipolar disorder and is experiencing mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse take? a. "You are already too thin and exercise is not good for you. Go sit down somewhere and eat something." b. "Come with me. Here is a milkshake to drink." c. "We need you to decide what activities you will do today." d. "You will need to leave the dining room right now and go somewhere else to exercise."

b. "Come with me. Here is a milkshake to drink."

An acutely depressed patient isolates herself in her room and just sits and stares into space. Which of these is the best example of an active communication approach with this patient? a. "Do you like exercise?" b. "Come with me. I will go with you to group therapy." c. "Would you like to go to group therapy, stay in bed, or come out to the day lounge for some activities?" d. "Why do you stay in your room atll the time?"

b. "Come with me. I will go with you to group therapy."

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? a. "Why do you think you feel the need to give money away?" b. "I am here to provide care and cannot accept this from you." c. "I can request that your case manager discuss appropriate charity options with you." d. "You should know that giving away your money is inappropriate."

b. "I am here to provide care and cannot accept this from you."

A nurse is caring for a client who has borderline personality disorder. As part of the client's plan of care, the nurse reviews the day's schedule with the client each morning. As the nurse begins to review the schedule with the client, the client says, "Why don't you shut up already? I can read it myself, you know!" Which of the following responses should the nurse give the client? a. "we do this everyday. Why are you so angry with me this morning?" b. "I don't like it when you address me with that tone of voice." c. "I know you can, but are you going to read it or not?" d. "Fine. Here is the schedule and I will expect you to be on time to your therapies."

b. "I don't like it when you address me with that tone of voice."

The physician orders sertraline (Zoloft) 50 mg PO bid for Margaret, a 68-year-old woman with major depressive disorder. After 3 days of taking the medication, Margaret says to the nurse, "I don't think this medicine is doing any good. I don't feel a bit better." What is the most appropriate response by the nurse? a. "Cheer up, Margaret. You have so much to be happy about." b. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms." c. "I'll report that to the physician, Margaret. Maybe he will order something different." d. "Try not to dwell on your symptoms, Margaret. Why don't you join the others down in the dayroom?"

b. "Sometimes it takes a few weeks for the medicine to bring about an improvement in symptoms."

Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the emergency department by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of which of the following? a. A delusion of grandeur b. A delusion of persecution c. A delusion of reference d. A delusion of control or influence

b. A delusion of persecution

Which of the following behavioral patterns is characteristic of individuals with schizotypal personality disorder? a. Belittling themselves and their abilities b. A lifelong pattern of social withdrawal c. Suspiciousness and mistrust of others d. Overreacting inappropriately to minor stimuli

b. A lifelong pattern of social withdrawal

"Splitting" by the client with BPD denotes which of the following? a. Evidence of precocious development b. A primitive defense mechanism in which the client sees objects as all good or all bad c. A brief psychotic episode in which the client loses contact with reality d. Two distinct personalities within the borderline client

b. A primitive defense mechanism in which the client sees objects as all good or all bad

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

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

What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? a. The attention during the assessment is beneficial in decreasing social isolation b. Depression can generate somatic symptoms that can mask actual physical disorders c. Physical health complications are likely to arise from antidepressant therapy d. Depressed clients avoid addressing physical health and ignore medical problems.

b. Depression can generate somatic symptoms that can mask actual physical disorders

A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar depression. Which of the following statements by the newly licensed nurse indicates understanding? a. "ECT is the recommended initial treatment for bipolar disorder." b. "ECT is contraindicated for clients who have suicidal ideations." c. "ECT is effective for clients who are experiencing severe mania." "ECT is prescribed to prevent relapse of bipolar disorder

c. "ECT is effective for clients who are experiencing severe mania."

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (SATA) a. Use caffeine in moderation to prevent relapse b. Difficulty sleeping can indicate a relapse c. Begin taking your medications as soon as a relapse begins d. Participating in psychotherapy can help prevent a relapse e. Anhedonia is a clinical manifestation of a depressive relapse.

b. Difficulty sleeping can indicate a relapse d. Participating in psychotherapy can help prevent a relapse e. Anhedonia is a clinical manifestation of a depressive relapse.

Milieu therapy is a good choice for patients with antisocial personality disorder because it: a. Provides a system of punishment and rewards for behavior modification. b. Emulates a social community in which the patient may learn to live harmoniously with others. c. Provides mostly one-to-one interaction between the patient and therapist. d. Provides a structured setting in which the patients have very little input into the planning of their care.

b. Emulates a social community in which the patient may learn to live harmoniously with others.

When assessing a client diagnosed with narcissistic personality disorder, the nurse expects to identify which characteristic behavior? a. Odd beliefs and magical thinking b. Grandiose sense of self-importance c. Pattern of intense and chaotic relationships d. Submissive and clinging behaviors

b. Grandiose sense of self-importance

A nurse is caring for 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 US Senator." Which of the following findings is this client exhibiting? a. Flight of ideas b. Grandiosity c. Reality testing d. Derealization

b. Grandiosity

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (SATA) a. Male sex b. History of chronic bronchitis c. Recent death in client's family d. Family history of depression e. Personal history of panic disorder

b. History of chronic bronchitis c. Recent death in client's family d. Family history of depression e. Personal history of panic disorder

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (SATA) a. Provide flexible client behavior expectations b. Offer concise explanations c. Establish consistent limits d. Disregard client concerns e. Use a firm approach with communication

b. Offer concise explanations c. Establish consistent limits e. Use a firm approach with communication

a nurse recently admitted a client to an inpatient unit after a suicide attempt a HCP orders amitriptyline for the client. Which intervention, related to this medication, should be initiated to maintain this client's safety upon discharge? a. Provide a 6month supply of Elavil to ensure long term compliance b. Provide a 1 week supply of Elavil with refills contingent on follow up appointments c. Provide pill dispenser as a memory aid d. Provide education regarding the avoidance of foods containing tyramines

b. Provide a 1 week supply of Elavil with refills contingent on follow up appointments

Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. Margaret is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. What is the priority nursing diagnosis for Margaret? a. Imbalanced nutrition: Less than body requirements related to not eating b. Risk for injury related to hyperactivity c. Disturbed sleep pattern related to agitation d. Ineffective coping related to denial of depression

b. Risk for injury related to hyperactivity

68 y/o recent widow is hospitalized for isolation, weight loss and suicidal ideation. Which nursing diagnosis is priority? a. Imbalance nutrition: less than body requirements b. Risk for suicide c. Complicated grieving d. Social isolation

b. Risk for suicide

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to the client to address a behavioral symptom of this disorder? a. Altered communication R/T feelings of worthlessness AEB anhedonia b. Social isolation r/t poor self esteem aeb secluding self in room c. Altered thought processes r/t hopelessness aeb persecutory delusions d. Altered nutrition: less than body requirements r/t high anxiety aeb anorexia

b. Social isolation r/t poor self esteem aeb secluding self in room

A nurse is caring for a client who has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement as an example of which of the following defense mechanisms? a. Regression b. Splitting c. Undoing d. Identification

b. Splitting

A suicidal client with a history of manic behavior is admitted to the emergency department. The client's diagnosis is documented as bipolar 1 disorder: current episode depressed. What is the rationale for this diagnosis instead of a diagnosis of major depressive disorder? a. The physician does not believe the client is suffering from major depression b. The client has experienced a manic episode in the past c. The client does not exhibit psychotic symptoms d. There is no history of major depression in the client's family

b. The client has experienced a manic episode in the past

When teaching about the tricyclic group of antidepressant medications, which information should the nurse include? a. Strong or aged cheese should not be eaten while taking this group of medications b. The full therapeutic potential of tricyclics may not be reached for 4 weeks c. Long-term use may result in physical dependence d. Tricyclics should not be given with anti-anxiety agents

b. The full therapeutic potential of tricyclics may not be reached for 4 weeks

A nurse is educating a patient about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the patient to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia

b. Tinnitus, severe diarrhea, ataxia

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client? a. Watching a video with a group in the day room b. Walking with the nurse in the courtyard c. Participating in a basketball game in the gym d. Joining a group discussion about a local election.

b. Walking with the nurse in the courtyard

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? a. Chess b. Writing c. Board games d. Group exercise

b. Writing

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? a. "I don't believe this is true." b. "The guards are not out to kill you." c. "Do you feel afraid that people are trying to hurt you?" d. "What makes you think the guards were sent to hurt you?"

c. "Do you feel afraid that people are trying to hurt you?"

a nurse assesses a client suspected of having major depressive disorder. Which client symptoms would eliminate this diagnosis? a. The client is disheveled and malodorous b. The client refuses to interact with others c. Maxed out credit cards and sexual behavior

c. Maxed out credit cards and sexual behavior

A nurse is teaching a client who has a new diagnosis of PMDD. Which of the following statements by the client indicates understanding of the teaching? a. "I can expect my problems with PMDD to be worst when I'm menstruating." b. "I should avoid exercising when I am feeling depressed." c. "I am aware that my PMDD causes me to have rapid mood swings." "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

c. "I am aware that my PMDD causes me to have rapid mood swings."

A nurse manager is discussion the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "I can promote my client's sense of control by establishing a schedule." b. "I should encourage clients who have a schizoid personality disorder to increase socialization." c. "I should practice limit setting to help prevent client manipulation." d. "I should implement assertiveness training with clients who have antisocial personality disorder."

c. "I should practice limit setting to help prevent client manipulation."

A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates an understanding of the teaching? a. "I need to make a voluntary choice to stop feeling depressed." b. "I can cure my depression by thinking positive thoughts." c. "I will attend psychotherapy to help manage my depression." d. "I will plan on my antidepressant taking 3 to 5 days to be effective."

c. "I will attend psychotherapy to help manage my depression."

A nurse is caring for a client who has depression. The client refuses to get out of bed go to activities or participate in any of unit's programs. Which of the following responses should the nurse make? a. "You really need to follow the rules of the unit and get out of bed." b. "If you do not get out of bed you will not receive your meal." c. "I will help you get ready and then you can rest after activities." d. "You should rest until you feel able to join the group."

c. "I will help you get ready and then you can rest after activities."

Sertraline 50mg qd is started. After 3 days she reports, "I don't feel a bit better." What response is most appropriate? a. "Cheer up. You have so much to be happy about" b. "I'll report that to the physician." c. "Sometimes it takes a few weeks to bring about an improvement." d. Try not to dwell on your symptoms, go to group."

c. "Sometimes it takes a few weeks to bring about an improvement."

A charge nurse is discussing the care of a client who has major depressive disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "Care during the continuation phase focuses on treating continued manifestations of MDD." b. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." c. "The client is at greatest risk for suicide during the first weeks of an MDD episode." d. "Medication and psychotherapy are most effective during the acute phase of MDD."

c. "The client is at greatest risk for suicide during the first weeks of an MDD episode."

A client feels guilty for being angry at her husband who would not stop smoking and died of lung cancer. Best response? a. He should have stopped smoking b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response." d. "Just think about the good times that you had"

c. "Those feelings are a normal part of the grief response."

A patient whose husband died 6 months ago is diagnosed with major depressive disorder. She says to the nurse, "I start feeling angry that Harold died and left me all alone; he should have stopped smoking years ago! But then I start feeling guilty for feeling that way." What is an appropriate response by the nurse? a. "Yes, he should have stopped smoking. Then he probably wouldn't have gotten lung cancer." b. "I can understand how you must feel." c. "Those feelings are a normal part of the grief response." d. "Just think about the good times that you had while he was alive."

c. "Those feelings are a normal part of the grief response."

A nurse is assisting with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? SATA a. Demonstrates extreme anxiety when placed in a social situation b. Often engages in magical thinking c. Attempts to convince other clients to relinquish their belongings d. Becomes agitated if personal area is not neat and orderly e. Blames others for personal past and current problems.

c. Attempts to convince other clients to relinquish their belongings e. Blames others for personal past and current problems.

A charge nurse is preparing a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the charge nurse include in the teaching? SATA a. Difficulty in getting along with other members of a group b. Belief in the ability to become invisible during times of stress c. Display of defense mechanisms when routines are changed d. Claiming to be more important than other persons e. Difficulty understanding why it is inappropriate to have a personal relationship with staff

c. Display of defense mechanisms when routines are changed e. Difficulty understanding why it is inappropriate to have a personal relationship with staff

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? a. Place the client in seclusion for 30 minutes b. Tell the client that the behavior is in appropriate c. Escort the client to their room with assistance from other staff d. Tell the client that their telephone privileges are revoked for 24 hours

c. Escort the client to their room with assistance from other staff

In assessing a client diagnosed with borderline personality disorder, which characteristic would the nurse expect to observe? a. Predictability b. Controlled anger c. Little tolerance for being alone d. Stable and satisfactory relationships

c. Little tolerance for being alone

A nurse is caring for a client who has bipolar disorder and a new prescription for valproate. Which of the following instructions should the nurse give the client about the use of this medication? a. Thyroid function tests should be performed every 6 months b. A pretreatment electroencephalogram (EEG) will be done c. Liver function tests must be monitored d. High serum sodium levels can cause toxic levels of valproate

c. Liver function tests must be monitored

In evaluating the progress of Jack, a patient diagnosed with antisocial personality disorder, which of the following behaviors would be considered the most significant indication of positive change? a. Jack got angry only once in group this week. b. Jack tells the nurse how much he respects her work and that she has helped him immensely. c. On his own initiative, Jack sent a note of apology to a man he had injured in a recent fight. d. Jack stated that he would not start any more fights

c. On his own initiative, Jack sent a note of apology to a man he had injured in a recent fight.

A client diagnosed with major depression with psychotic features hears voices commanding self-harm. A nurse is unable to elicit a contract for safety. What should be the nurses priority intervention at this time? a. Obtaining an order for locked seclusions until client is no longer suicidal b. Conducting 15 minute checks to ensure safety c. Placing the client on 1-1 monitoring while continue to monitor

c. Placing the client on 1-1 monitoring while continue to monitor

A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? a. Wide fluctuation in mood b. Report of a minimum of five clinical findings of depression c. Presence of manifestations for at least 2 years d. Inflated sense of self-esteem

c. Presence of manifestations for at least 2 years

Margaret, age 68, is diagnosed with bipolar I disorder, current episode manic. She is extremely hyperactive and has lost weight. What is one way to promote adequate nutritional intake for Margaret? a. Sit with her during meals to ensure that she eats everything on her tray. b. Have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." d. Tell Margaret that she will be on room restriction until she starts gaining weight.

c. Provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run."

Katerina, who is experiencing a manic episode, enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell her, in front of the other patients, that she cannot dress like a ***** while she is in the hospital. b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit, she must remain in her room

c. Quietly walk with her back to her room and help her change into something more appropriate.

Margaret, age 68, is a widow of 6 months. Since her husband died, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that "she doesn't have anything more to live for." She has been hospitalized with a diagnosis of Major Depressive Disorder. The priority nursing diagnosis for Margaret is: a. Imbalanced nutrition: Less than body requirements b. Complicated grieving c. Risk for suicide d. Social isolation

c. Risk for suicide

A nurse is caring for a client who is in the manic phase of bipolar disorder. The client is running around the unit trying to organize competitive games with the clients. Which of the following is an appropriate intervention? a. Recommend a game of table tennis with another client b. Suggest the client exercise on a stationary bike c. Take the client outside for a walk d. Praise the client's efforts to engage in social interaction

c. Take the client outside for a walk

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take? a. Discuss the problem in a community meeting with the other clients on the unit present. b. Escort the client to her room each time the nurse observes the client socializing with other clients. c. Talk to the client and identify the specific limits that are required of the client's behavior. d. Tell the other clients to ignore the client's lies

c. Talk to the client and identify the specific limits that are required of the client's behavior.

A child with bipolar disorder also has attention deficit-hyperactivity disorder (ADHD). How would these comorbid conditions most likely be treated? a. No medication would be given for either condition. b. Medication would be given for both conditions simultaneously. c. The bipolar condition would be stabilized first before medication for the ADHD would be given. d. The ADHD would be treated before consideration of the bipolar disorder.

c. The bipolar condition would be stabilized first before medication for the ADHD would be given.

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania? a. The client's spouse reports that client has recently gained weight b. The client is dressed in all black c. The client responds to questions with disorganized speech d. The client reports that voices are telling him to write a novel

c. The client responds to questions with disorganized speech

A client with depression asks, "why would they be checking my thyroid function? I'm not over weight?" Best response? a. Depression has been proven to be a hormonal illness b. An underactive thyroid gland can manifest as depression c. Thyroid hormone replacement is a first line treatment for most people d. Abnormal thyroid function predicts positive response to SSRIs

c. Thyroid hormone replacement is a first line treatment for most people

A nurse who works in a psychiatric unit is caring for a client who has BPD. The client comes to the nurses station at 0300 demanding that the nurse call the provider immediately. Which of the following response by the nurse is appropriate? a. "You are being unreasonable, and I will not call your doctor at this hour." b. "Go back to your room, and I'll try to get in touch with your doctor," c. "I can't call a doctor in the middle of the night unless it's an emergency." d. "You must be very upset about something."

d. "You must be very upset about something."

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 include which intervention? a. Encouraging quiet reading and writing for the first few days b. Identification of physical activities that will provide exercise c. No socializing activities until the client asks to participate in milieu d. A structured program of activities in which the client can participate.

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

Which of the following is the most common comorbid condition in children with bipolar disorder? a. Schizophrenia b. Substance disorders c. Oppositional defiant disorder d. Attention deficit-hyperactivity disorder

d. Attention deficit-hyperactivity disorder

A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression? a. Being married b. Pregnancy c. Male gender d. Chronic illness

d. Chronic illness

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following? a. Limit the amount of time available to interact with others b. Focus attention on meaningful tasks c. Manipulate and control others' behaviors d. Decrease anxiety to a tolerable level

d. Decrease anxiety to a tolerable level

A client diagnosed with borderline personality disorder is admitted to a psychiatric unit. Which behavior pattern would the nurse expect to observe? a. Social isolation b. Suspiciousness of others c. Bizarre speech patterns d. Generated conflict among the staff

d. Generated conflict among the staff

A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take? a. The Monitor the client closely to prevent self-mutilation b. Set limits to prevent exploitation of other clients c. Discourage flamboyant or seductive behaviors d. Give positive feedback when client is assertive with staff or clients.

d. Give positive feedback when client is assertive with staff or clients.

An individual experienced the death of a parent 2 years ago. This individual has not been able to work since the death, cannot look at any of the parent's belongings, and cries daily for hours at a time. Which nursing diagnosis most accurately describes this individual's problem? a. Post-trauma syndrome related to parents death b. Anxiety (severe) related to parent's death c. Coping, ineffective related to parent's death d. Grieving complicated related to parent's death

d. Grieving complicated related to parent's death

A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action? a. Set consistent limits for expected client behavior. b. Administer prescribed medication as scheduled. c. Provide the client with step-by-step instructions during hygiene activities. d. Monitor the client for escalating behavior

d. Monitor the client for escalating behavior

A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action? a. Identifying support systems b. Assisting the client in identifying coping behaviors. c. Encouraging self-care d. Preventing self-directed violence

d. Preventing self-directed violence

Kim has a diagnosis of BPD. She often exhibits alternating clinging and distancing behaviors. Which of the following is the most appropriate nursing intervention with this type of behavior? a. Encourage Kim to establish trust in one staff person with whom all therapeutic interaction should take place. b. Secure a verbal contract from Kim that she will discontinue these behaviors. c. Withdraw attention if these behaviors continue. d. Rotate staff members who work with Kim so that she will learn to relate to more than one person.

d. Rotate staff members who work with Kim so that she will learn to relate to more than one person.

Jessica is a nurse who was floated to the psychiatric unit to cover for a staff nurse who called out sick. She encounters a patient who is diagnosed with BPD, and the patient states, "Thank goodness they sent you to the unit. No one else here has taken the time to listen to my concerns." This may be an example of which symptom common in BPD? a. Impulsivity b. Self-harming behaviors c. Dissociation d. Splitting

d. Splitting

A client becomes very dejected and states, "no one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make? a. I care about you and I am concerned that you feel so sad b. Of course people care. Your family comes to visit every day c. Why do you feel that way? d. Tell me who you think doesn't care about you

d. Tell me who you think doesn't care about you

Education for the patient who is taking MAOIs should include which of the following? a. Fluid and sodium replacement when appropriate, frequent drug blood levels b. Short-term use, possible tolerance to effects, careful tapering to DC c. Lifetime use, possible tardive dyskinesia, advantage of monthly injections d. Tyramine-restricted diet, concurrent use of OTC meds need HCP approval

d. Tyramine-restricted diet, concurrent use of OTC meds need HCP approval

Education for the patient who is taking MAOIs should include which of the following? a. Fluid and sodium replacement when appropriate, frequent drug blood levels, signs and symptoms of toxicity b. Lifetime of continuous use, possible tardive dyskinesia, advantages of an injection every 2 to 4 weeks c. Short-term use, possible tolerance to beneficial effects, careful tapering of the drug at end of treatment d. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification

d. Tyramine-restricted diet, prohibitive concurrent use of over-the-counter medications without physician notification

A nurse is planning care for a child who is experiencing depression which med is approved by the FDA for the treatment of depression in children and adolescents? a. Paxil b. Zoloft C. Celexa d. prozac

d. prozac