NCLEX Project Class Number 2

A nurse in an acute care mental health facility to administer morning medication for a client who has been taking lithium for 2 weeks and has a current level of 1.0 mEq/L. Which of the following actions should the nurse take?

Administer the morning dose of lithium

A nurse is preparing to administer selegiline for a client who is admitted with major depression. Which of the following actions should the nurse take?

Apply to dry skin on the client's upper thigh

A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicated an understanding of the teaching?

" I will attend psychotherapy to help manage my depression"

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?

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

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

- Offer finger foods to the client every 2 hr - Maintain an environment with low stimuli - Monitor vital signs every 1 to 2 hr throughout the day

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? (Select all that apply.)

- Paroxetine - Lithium - Valproate - Carbamazepine

A nurse in a mental health clinic is caring for a client who has bipolar disorder and a prescription for an antipsychotic medication. The provider and nursing staff suspect the client is not adhering to his medication therapy. Which of the following interventions should the staff use to encourage the client's adherence? (Select all that apply.)

- Provide for once-daily dosing - Use sustained-release forms - Engage the client in conversation following medication administration

A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicated a need for further evaluation?

"I just don't like going to the movies like I used to"

A nurse is evaluating teaching for a client who has newly diagnosed depression and a new prescription for bupropion. Which of the following statements by the client indicated understanding of the teaching?

"I may not notice a lifting of my mood for at least 2 weeks"

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?

"I see you have done some grooming today"

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 the unit's programs. Which of the following responses should the nurse make?

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

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

"I'll just sit here with you for a few minutes then"

A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching?

"I'll take this medicine first thing in the morning"

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of this condition?

"Postpartum depression is more likely to occur in women who have a history of depression"

A nurse is teaching a client who plans to take St. John's wort to treat her depression. Which of the following information should the nurse include in the teaching?

"You may experience vivid dreams while taking St. John's wort"

A nurse in the emergency department is preparing to administer naloxone 0.4 mg IV bolus to a client who has opioid-induced respiratory depression. Available is naloxone injection 0.2 mg/ml. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?

A private room in a quiet location on the unit

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 the client?

A private room in a quiet location on the unit

A charge nurse is conducting staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?

Chronic illness

A nurse is caring for a client who has paraplegia following a diving accident. Which of the following findings indicated that the client is developing depression?

Difficulty concentrating

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Experiencing diarrhea

A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Give the client extra time to communicate needs

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 U.S. Senator." Which of the following findings is this client exhibiting?

Grandiosity

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

Have consistent unit routines

A nurse is caring for a client who has depression and is discussing activities of daily living (ADLs) with his family. The nurse should identify that the client can perform which of the following activities prior to discharge?

Hygiene

A nurse in an acute mental health facility is caring for a client who has depression. After 3 days of treatment, the nurse notices that the client suddenly seems cheerful and relaxed and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?

Monitor the client's whereabouts at all times

A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Initiating suicide precautions

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 take first?

Inspect the cuts for debris

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?

Liver function tests must be monitored

A nurse is caring for a newborn who has respiratory depression. Which of the following medications should the nurse anticipate administering?

Naloxone

A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder?

Past history of childhood trauma

A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?

Sit with the client and offer simple, direct information

A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

Sodium

A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?

Spending time sitting with the client

A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?

Take the client outside and sit with her in the garden area

A nurse is teaching a client who has depression about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching?

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

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?

The client responds to questions with disorganized speech

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

Thyroid hormone assay

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 appropriated for the nurses to suggest to this client?

Walking with the nurse in the courtyard

A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the client indicates understanding of the teaching?

"I should notify my provider if I develop a skin rash"

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicated an understanding of the teaching?

"Vomiting is an indication of toxicity"

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurses is appropriate?

"You must be very upset about something"

A nurse is preparing to teach a client about his prescription of lithium for the treatment of bipolar disorder. Which of the following statements should the nurse include in the teaching?

"You will need to stop this medication if you experience diarrhea"

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)

- Irritability - Insomnia - Low self-esteem - Chronic pain

A nurse is caring for a client who is to undergo electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse take prior to scheduled ECT? (Select all that apply.)

- Request an ECG - Witness the informed consent - Check the client's blood pressure

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)

- Talking in rapid, continuous speech - Interacting with others in a flirtatious way - Spending large sums of money

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?

Ask the client is she has a plan to commit suicide

A nurse is reviewing discharge instructions with a client who has bipolar disorder and is taking lithium. Which of the following manifestations should the nurse include as an indication of mild toxicity?

Muscle weakness

A nurse is providing discharge teaching to a client who has bipolar disorder 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?

The client runs 4 miles outdoors every afternoon.

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?

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