Mood Pass Point

The nurse is about to administer lithium carbonate to a client with bipolar disorder in a mania state. What is the nurse's action after assessing the client's lithium level to be 1.0 mEq/L (mmol/L)?

Administer the lithium carbonate.

A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication?

Avoid alcohol.

The mental health unit provides a unit landline for clients to use for telephone calls. A client with bipolar disorder is monopolizing the use of the telephone by making several calls each day, interfering with the ability of other clients to use the telephone. What should the nurse do?

Limit the amount of calls the client can make each day.

Which food should the nurse tell the client to avoid while taking phenelzine?

Salami

A nurse notices that a client admitted for treatment of major depression is pacing, agitated, and becoming verbally aggressive toward other clients. What is the immediate care priority?

ensuring the safety of this client and other clients on the unit

A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding?

exhaustion

An elderly client's lithium level is 1.4 mEq/L. The client complains of diarrhea, tremors, and nausea. The nurse should:

hold the lithium and notify the physician.

A client with major depression has been admitted for medical workup before the initiation of a series of electroconvulsive therapy (ECT) treatments. While the nurse is conducting pretreatment education with the family, the client's child asks, "Isn't this treatment dangerous?" What is the most appropriate nursing response?

"Although there are some risks, your parent will have a thorough examination in advance to ensure that they are a good candidate for the treatment."

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take?

Question the physician about the order.

A nurse is prioritizing care for four new admissions to the inpatient psychiatric unit. Which client should the nurse assess first?

a client with new-onset confusion and disorientation.

Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills?

determining if the client's physical condition is life-threatening

An adolescent client took 300 acetaminophen tablets in an attempt to kill themself after a relationship breakup. The client is admitted to the adolescent psychiatric unit and is refusing to talk with the nurse. What is the most important nursing approach at this stage of the helping relationship?

supporting suicide precautions and safety measures for the client on the unit

The husband of a client who was diagnosed 6 years ago with Alzheimer's disease approaches the nurse and says, "I'm so excited that my wife is starting to use donepezil for her illness." What should the nurse tell the husband?

the medication is effective mostly in the early stages of the illness.

The nurse is meeting weekly with an adolescent recently diagnosed with depression to monitor progress with therapy and antidepressant medication. The nurse should be most concerned when the client reports what information?

An acquaintance hanged herself two days ago.

The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next?

Call the health care provider (HCP) immediately to report changes.

A client has experienced the death of their spouse. They were married for 50 years and the client depended on the spouse for simple activities of daily living. Which factors would be the priority nursing interventions to reduce the effects of acute stress in this client? Select all that apply.

Encourage the client to gain optimism for the future. Assess the client's social support. Assess the client's physical health. Assess the client's coping skills.

A client taking disulfiram during alcohol rehabilitation therapy reports to the nurse that they have a mild cold and plan to use a cough medicine. Which statement made by the client indicates understanding of the nurse's teaching?

I may experience vomiting and an upset stomach if I take cough medicine while taking this medicine."

While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. What should the nurse tell the husband?

Ignore and distract

nurse is coordinating outpatient care for a 38-year-old client who is homeless and has a history of chronic schizophrenia. Which one intervention would be best for the nurse to suggest for this client?

a life and social skills group

The health care provider prescribes risperidone for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which behavior?

agitation and aggression

A client is in the first stage of Alzheimer's disease. The nurse should plan to focus this client's care on:

providing emotional support and individual counseling.

The history of a female client who has just been admitted to the unit and is very depressed reveals a weight loss of 10 lb (4.5 kg) in 2 weeks, sleeping 3 hours a night, and poor hygiene. The client states, "I'm no good to anyone. Everyone would be better off without me." Which question should the nurse ask first?

"Are you thinking about hurting yourself?"

During a home visit to an older adult with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply.

Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. Promote relaxation before bedtime with a warm bath or relaxing music.

A client with acute mania exhibits euphoria, pressured speech, and flight of ideas. The client has been talking to the nurse nonstop for 5 minutes and lunch has arrived on the unit. What should the nurse do next?

Excuse oneself while telling the client to come to the dining room for lunch.

The nurse is assessing a client with bipolar disorder during a follow-up appointment after initiating treatment with lithium carbonate. Which symptom would cause the nurse to suspect lithium toxicity?

GI upset

A client and her partner come to the clinic stating they have been unable to have sexual intercourse. The female client states she has pain and her "vagina is too tight." The client was raped at age 15 years of age. Which nursing problem is most appropriate for this client?

Sexual dysfunction related to sexual trauma

The nurse attempts to interact with a client who barely responds with yes or no. The client states, "Don't bother me. I want to die." What action should the nurse take?

Sit with the client.

A nurse is taking an admission history, including a medication list, from a client. The listing of which herbal medication would prompt the nurse to ask the client more questions regarding any history of depressive symptoms?

St.Johns wart

A client with depression states, "I'm still feeling nauseous after I take venlafaxine. Maybe I need something else." What should the nurse should tell the client to do?

Take the medication at mealtime.

A client of Hispanic ethnicity has recently immigrated to this country and has been admitted for depression. The nurse documents that the client has poor eye contact during the medication teaching session. What is the most likely reason for the client's behavior?

The client is demonstrating respect for the nurse.

A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which client goal would be most appropriate?

The client will refrain from hugging other clients and change clothing only twice per day.

A client has just been admitted with acute delirium of unknown etiology. The client's daughter states that she is worried about her mom because she has never been this sick before. Which would be the most helpful statement to make to the daughter?

The health care provider will prescribe tests to find out what's causing her condition."

In the weeks following a natural disaster, a nurse is assessing clients at a community mental health center. A client reports symptoms of waking up early and being unable to go back to sleep. The client also reports headaches. muscle aches, and having problems staying focused at work. How does the nurse best respond to this client?

These symptoms are normal responses by your body to stress."

The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, "I am the Queen of England. Bow before me." The nurse interprets this statement as important to document as which area of the mental status examination?

Thought content

A nurse is caring for a client diagnosed with antisocial personality disorder. This client has a history of fighting, cruelty to animals, and stealing. Which trait is the nurse likely to uncover during assessment?

a low tolerance for frustration

When the nurse is developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include?

management of common adverse effects

A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client:

may be experiencing increased energy and is at increased risk for suicide.

A client with Alzheimer's disease is admitted to an inpatient setting and has memory loss, wandering, and disorientation. What nursing intervention should be the priority to initiate in the client's care plan?

Remove potential hazards from the client's environment.

A client is in the manic phase of chronic bipolar disorder. The client has stopped taking the prescribed lithium carbonate 3 weeks ago and has not been eating or sleeping for 3 days. Which behaviors will be of priority concern as the nurse begins a care plan for this client?

hyperactivity, ignoring eating and sleeping

A client with depression is exhibiting a brighter affect, ability to attend to hygiene and grooming tasks, and is beginning participation in group activities. The nurse asks the client to identify three of her strengths. After much hesitation and thinking, the client can state she is usually a nice person, a good cook, and a hard worker. What should the nurse do next?

Reinforce the client for identifying and sharing her strengths.

Which behaviors from a client with dementia would prompt nursing intervention?

attempting to hit others

The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client's plan of care?

cleaning the dayroom tables

A nurse is caring for an elderly client in a long-term care facility. This client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?

removing items that the client could use in a suicide attempt

A nurse is counseling an adolescent client for depression. The client's father died 2 months ago of cancer, and the client's mother died when the client was 11 years old. During the interview the client states, "I just feel like I can't do anything." Which of the following would be most appropriate response to this client?

"I will stay here with you."

The nurse is assigned to care for a client admitted with depression as well as a dependent personality disorder. Which statement by the client is indicative of this personality disorder?

"Please don't forget to wait for me to go to dinner. I don't want to go by myself."

A healthcare provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid?

Follow-up blood tests are necessary while on this medication.

A nurse notices that a severely depressed client is crying and asks what's wrong. The client responds, "Well, it looks like my suspicions are about to be confirmed." When asked what that means, the client refuses to talk about the matter. The nurse later notices a letter from the client's spouse lying on the floor near the bed. The client is in session with the psychiatrist and the nurse believes the contents of the letter could offer clues about the client's depression. What is the nurse's best course of action?

Pick up the letter and place it on the client's bedside table