PSY 2 Chapter 26, 25, 17, 13, 35

A nurse is caring for four clients diagnosed with major depression. When considering the client's belief system, which client would potentially be at highest risk for suicide? A. Roman Catholic B. Protestant C. Atheist D. Muslim

ANS: C Depressed men and women who consider themselves affiliated with a religion are less likely to attempt suicide than their nonreligious counterparts.

8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? A. "I know that it was not my fault." B. "My boyfriend has trouble controlling his sexual urges." C. "If I don't put myself in a dating situation, I won't be at risk." D. "Next time I will think twice about wearing a sexy dress."

A The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

18. Order the description of the progressive phases of Walker's model of the "cycle of battering?" ________ This phase is the most violent and the shortest, usually lasting up to 24 hours. ________ In this phase, the man's tolerance for frustration is declining. ________ In this phase, the batterer becomes extremely loving, kind, and contrite.

2,1,3 In her classic studies of battered women and their relationships, Walker identified a cycle of predictable behaviors that are repeated over time. The behaviors can be divided into three distinct phases that vary in time and intensity both within the same relationship and among different couples. 1. Tension building phase. In this phase, the man's tolerance for frustration is declining. 2. Acute battering incident phase. This phase is the most violent and the shortest, usually lasting up to 24 hours. 3. Honeymoon phase. In this phase, the batterer becomes extremely loving, kind, and contrite.

1. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the child's face and arms. What other symptom should indicate to the nurse that the child may have been physically abused? A. The child shrinks at the approach of adults. B. The child begs or steals food or money. C. The child is frequently absent from school. D. The child is delayed in physical and emotional development.

A The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns may be a victim of abuse. Maltreatment is considered, whether or not the adult intended to harm the child.

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

13. Which assessment data should a school nurse recognize as a sign of physical neglect? A. The child is often absent from school and seems apathetic and tired. B. The child is very insecure and has poor self-esteem. C. The child has multiple bruises on various body parts. D. The child has sophisticated knowledge of sexual behaviors.

A The nurse should recognize that a child who is often absent from school and seems apathetic and tired may be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

3. Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence? A. Power and control are central to the dynamic of domestic violence. B. Poor communication and social isolation are central to the dynamic of domestic violence. C. Erratic relationships and vulnerability are central to the dynamic of domestic violence. D. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

A The nursing instructor should include the concept that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client? A. The more specific the plan is, the more likely the client will attempt suicide. B. Clients who talk about suicide never actually commit it. C. Clients who threaten suicide should be observed every 15 minutes. D. After a brief assessment, the nurse should avoid the topic of suicide.

ANS: A Clients who have specific plans are at greater risk for suicide.

Which client data indicate that a suicidal client is participating in a plan for safety? A. Compliance with antidepressant therapy B. A mood rating of 9/10 C. Disclosing a plan for suicide to staff D. Expressing feelings of hopelessness to nurse

ANS: C A degree of the responsibility for the suicidal client's safety is given to the client. When a client shares with staff a plan for suicide, the client is participating in a plan for safety by communicating thoughts of self-harm that would initiate interventions to prevent suicide.

A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client? A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers

ANS: A Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

16. Which of the following nursing diagnoses are typically appropriate for an adult survivor of incest? (Select all that apply.) A. Low self-esteem B. Powerlessness C. Disturbed personal identity D. Knowledge deficit E. Non-adherence

A,B An adult survivor of incest would most likely have low self-esteem and a sense of powerlessness. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

17. A nursing instructor is teaching about intimate partner violence. Which of the following student statements indicate that learning has occurred? (Select all that apply.) A. "Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner." B. "Intimate partner violence is used to gain power and control over the other intimate partner." C. "Fifty-one percent of victims of intimate violence are women." D. "Women ages 25 to 34 experience the highest per capita rates of intimate violence." E. "Victims are typically young married women who are dependent housewives."

A,B,D Intimate partner violence is a pattern of abusive behavior that is used by an intimate partner. It is used to gain power and control over the other intimate partner. Women ages 25 to 34 experience the highest per capita rates of intimate violence. Eighty-five percent of victims of intimate violence are women. Battered women represent all age, racial, religious, cultural, educational, and socioeconomic groups. They may be married or single, housewives or business executives.

15. In planning care for a woman who presents as a survivor of domestic abuse, a nurse should be aware of which of the following data? (Select all that apply.) A. It often takes several attempts before a woman leaves an abusive situation. B. Substance abuse is a common factor in abusive relationships. C. Until children reach school age, they are usually not affected by abuse between their parents. D. Women in abusive relationships usually feel isolated and unsupported. E. Economic factors rarely play a role in the decision to stay.

A,B,D When planning care for a woman who is a survivor of domestic abuse, the nurse should be aware that it often takes several attempts before a woman leaves an abusive situation, that substance abuse is a common factor in abusive relationships, and that women in abusive relationships usually feel isolated and unsupported. Children can be affected by domestic violence from infancy, and economic factors often play a role in the victim's decision to stay.

A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

ANS: A A client raised in an environment that reinforces one's inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms.

A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. "I am sad most of the time and I've felt this way for the last several years." B. "I find myself preoccupied with death." C. "Sometimes I hear voices telling me to kill myself." D. "I'm afraid to leave the house."

ANS: A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, "You can't do this to me. Do you know who I am?" Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation

ANS: A During a manic episode the client's mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client has been brought to the emergency department for signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation? A. Assessing the client's pulse oximetry and vital signs B. Developing a plan for safety for the client C. Assessing the client for suicidal ideations D. Establishing a trusting nurse-client relationship

ANS: A It is important to prioritize client interventions that assess the symptoms of COPD prior to any other nursing intervention. Physical needs must be prioritized according to Maslow's hierarchy of needs. This client's problems with oxygenation will take priority over assessing for current suicidal ideations.

After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. "Are you currently thinking about harming yourself?" B. "Why do you want to harm yourself?" C. "Have you thought about the consequences of your actions?" D. "Who is your emergency contact person?"

ANS: A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 pounds by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

ANS: A The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

A client who has been diagnosed with bipolar I disorder states, "God has taught me how to decode the Bible." A nurse should anticipate that which combination of medications would be ordered to address this client's symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal)

ANS: A The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment

ANS: A The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose. KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care

Which nursing intervention strategy is most appropriate to implement initially with a suicidal client? A. Ask a direct question such as, "Do you ever think about killing yourself?" B. Ask client, "Please rate your mood on a scale from 1 to 10." C. Establish a trusting nurse-client relationship. D. Apply the nursing process to the planning of client care.

ANS: A The risk of suicide is greatly increased if the client has suicidal ideations, has developed a plan, and particularly if means exist for the client to execute the plan.

A client diagnosed with bipolar disorder states, "I hate oatmeal. Let's get everybody together to do exercises. I'm thirsty and I'm burning up. Get out of my way; I have to see that guy." What should be the priority nursing action? A. Assess the client's vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.

ANS: A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The client's statement of "I'm thirsty and I'm burning up" could be a symptom of either infection or dehydration and must be assessed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of CareANS: A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The client's statement of "I'm thirsty and I'm burning up" could be a symptom of either infection or dehydration and must be assessed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age. D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant.

ANS: A, B It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? Select all that apply. A. "Tell me what happened." B. "What coping methods have you used, and did they work?" C. "Describe to me what your life was like before this happened." D. "Let's focus on the current problem." E. "I'll assist you in selecting functional coping strategies."

ANS: A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

After a teenager reveals that he is gay, the father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal emotions should a nurse anticipate? (Select all that apply.) A. Shock and disbelief B. Guilt and remorse C. Anger and resentment D. Bargaining and depression E. Denial and rationalization

ANS: A, B, C Suicide of a family member can induce a whole gamut of feelings in the survivors. Shock, disbelief, guilt, remorse, anger, and resentment are all feelings that may be experienced by this father.

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2,500 to 3,000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1,500 mL per day.

ANS: A, B, C The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. "I'll have to let my surgeon know about this medication 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."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions.

Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? Select all that apply. A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid "I" statements related to expression of feelings.

ANS: A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the client's anger. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

ANS: A, C, D Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post-menses

A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? (Select all that apply.) A. In the Middle Ages, suicide was viewed as a selfish and criminal act. B. During the Roman Empire, suicide was treated by incineration of the body. C. Suicide was an offense in ancient Greece, and a common site burial was denied. D. During the Renaissance, suicide was discussed and viewed more philosophically. E. Old Norse traditionally set a person who committed suicide adrift in the North Sea.

ANS: A, C, D These are true historical facts about suicide and should be included in the student's study guide.

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this 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

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence, and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

ANS: B Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

What is the priority reason 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 is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected.

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

A client is newly admitted to an inpatient psychiatric unit. Which assessment data are critical in determining an increased risk for suicide? A. Monitoring the client continually for 1 hour after admission B. Encouraging the client to discuss feelings C. Asking the client about any history of suicide attempts D. Removing hazardous materials from the environment

ANS: C A history of suicide attempts places a client at a higher risk for current suicide behaviors. Knowing this specific data will alert the nurse to the client's risk.

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread."

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. "I will limit my intake of fluids daily." B. "I will maintain normal salt intake." C. "I will take Lithobid on an empty stomach." D. "I will increase my caloric intake to prevent weight loss."

ANS: B A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

ANS: B Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? A. The client will not physically harm self. B. The client will express three positive self-attributes by day 4. C. The client will reveal a suicide plan. D. The client will establish a trusting relationship with the nurse by day 1.

ANS: B Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client centered, specific, realistic, measureable, and contain a time frame.

A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability

ANS: B Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A despondent client, who has recently lost her husband of 30 years, tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing reply is most appropriate? A. "I'm confident you know what's best for you." B. "This may not be the best time for you to make such an important decision." C. "Your children will be terribly disappointed." D. "Tell me why you want to make this change."

ANS: B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. This response encourages the client to think through what may be an impulsive decision. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client's spouse asks, "What evidence supports the possibility of genetic transmission of bipolar disorder?" Which is the best nursing reply? A. "Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors." B. "Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder." C. "Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress." D. "More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds."

ANS: B Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. "I can't stop my sexual urges. They have led me to numerous affairs." B. "I'm the world's most perceptive attorney." C. "My wife is distraught about my overspending." D. "The FBI is out to get me."

ANS: B Grandiosity is defined as a belief that personal abilities are better than anyone else's. This client is experiencing delusions of grandeur, which are commonly experienced in mania. KEY: Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Psychosocial Integrity

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. "Risky Activity" tool B. "FIND" tool C. "Consensus Committee" tool D. "Monotherapy" tool

ANS: B The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess? A. The client expresses "feeling blue most of the time." B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.

ANS: B The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? A. Provide a 6-month 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 a pill dispenser as a memory aid. D. Provide education regarding the avoidance of foods containing tyramine.

ANS: B The health-care provider should provide a 1-week supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential.

After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement? A. "I should expect to feel better in a couple of days." B. "I'll call my doctor immediately if I experience any diarrhea or ringing in my ears." C. "If I forget a dose, I can double the dose the next time I take this drug." D. "I need to restrict my intake of any food containing salt."

ANS: B The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which statement indicates that the nurse is acting as an advocate for a client who has recently made a suicide attempt? A. "I must observe you continually for 1 hour in order to keep you safe." B. "Let's confer with the treatment team about the triggers to your attempt that we discussed." C. "You must have been very upset to do what you did today." D. "Are you currently thinking about harming yourself?"

ANS: B The nurse is functioning in an advocacy role when collaborating with the client and treatment team to discuss client problems.

An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers.

ANS: B The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating. The nurse should conduct a thorough assessment of the client's past and current violent behaviors and develop interventions for de-escalation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis

ANS: B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or inability to assume personal responsibility. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |Client Need: Psychosocial Integrity

A stockbroker commits suicide after being convicted of insider trading. Which information should a nurse share with the grieving family? A. Your grieving will subside within 1 year; until then I recommend antidepressants. B. Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area. C. The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them. D. Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone.

ANS: B The nurse should discuss coping strategies that have been successful in times of stress in the past, and work to reestablish these within the family.

A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

ANS: B The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred? A. "This disorder is more prevalent in the lower socioeconomic groups." B. "This disorder is more prevalent in the higher socioeconomic groups." C. "This disorder is equally prevalent in all socioeconomic groups." D. "This disorder's prevalence cannot be evaluated on the basis of socioeconomic groups."

ANS: B The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance

A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L

ANS: B The therapeutic level of lithium carbonate is 1.0 to 1.5 mEq/L for acute mania and 0.6 to 1.2 mEq/L for maintenance therapy. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7 mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and so over these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care? A. "Has there been had any appetite or sleep changes?" B. "How often is your spouse left alone?" C. "Has your spouse been following a diet and exercise program consistently?" D. "How would you characterize your relationship with your spouse?"

ANS: B This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? A. Elderly people use less lethal means to commit suicide. B. While the elderly make up less than 13% of the population, they account for 16% of all suicides. C. Suicide is the second leading cause of death in the elderly. D. It is normal for elderly individuals to express a desire to die because they have come to terms with their mortality.

ANS: B This factual information should be included in the nursing instructor's teaching plan. An expressed desire to die is not normal in any age group.

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimer's disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this client's symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

ANS: C Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed.

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular bloodwork B. The client's mood and affect score, according to the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.

ANS: C A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be at risk for suicide. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment

A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurse's initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.

ANS: C During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurse's initial action should focus on removing the client from the stimulating environment to a calmer location. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

ANS: C Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care

A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply? A. "Suicide is a DSM-IV-TR diagnosis." B. "Suicide is a mental disorder." C. "Suicide is a behavior." D. "Suicide is an antisocial affliction."

ANS: C Suicide is not a diagnosis, disorder, or affliction. It is a behavior.

A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? A. Give the client off-unit privileges as positive reinforcement. B. Encourage the client to share mood improvement in group. C. Increase frequency of client observation. D. Request that the psychiatrist reevaluate the current medication protocol.

ANS: C The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act-out self-destructive behaviors prior to the client attaining the full therapeutic effect of the antidepressant medication.

What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken down" after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger

ANS: C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken down" after a violent outburst is to process feelings and concerns related to the witnessed intervention. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply? A. "That's strange. Weight loss is the typical pattern." B. "What have you been eating? Weight gain is not usually associated with lithium." C. "Weight gain is a common but troubling side effect." D. "Weight gain occurs only during the first month of treatment with this drug."

ANS: C The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide? A. Encouraging participation in the milieu to promote hope B. Developing a strong personal relationship with the client C. Observing the client at intervals determined by assessed data D. Encouraging and redirecting the client to concentrate on happier times

ANS: C The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment, the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3

ANS: C The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's physical and safety needs. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment: Management of Care

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time? A. Obtaining an order for locked seclusion until client is no longer suicidal B. Conducting 15-minute checks to ensure safety C. Placing the client on one-to-one observation while monitoring suicidal ideations D. Encouraging client to express feelings related to suicide

ANS: C The nurse's priority intervention when a client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideation.

A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention, and the rationale for this action? A. Administering lorazepam (Ativan) prn because the client is angry about the discovery of the note B. Establishing room restrictions because the client's threat is an attempt to manipulate the staff C. Placing this client on one-to-one suicide precautions because the more specific the plan, the more likely the client will attempt suicide D. Calling an emergency treatment team meeting because the client's threat must be addressed

ANS: C The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide. The appropriate nursing diagnosis for this client would be risk for suicide.

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations

ANS: C The priority nursing diagnosis for this client is "Risk for self-directed violence R/T hopelessness." Nurses should prioritize diagnoses and outcomes on the basis of potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order? A. This dosage is within the recommended dosage range. B. This dosage is lower than the recommended dosage range. C. This dosage is more than twice the recommended dosage range. D. This dosage is four times higher than the recommended dosage range.

ANS: C The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily. KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "Nothing will help me feel better."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder.

A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

A client diagnosed with major depressive disorder states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's affective symptoms? A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you ever felt this way before? C. "People who have mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood.

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.

A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? A. Communicate therapeutically. B. Observe the client. C. Provide a hazard-free environment. D. Assess suicide risk.

ANS: D Assessment is the first step of the nursing process to gain needed information to determine further appropriate interventions.

The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.

ANS: D Being available to actively listen, support, and accept feelings increases the potential that a client would confide suicidal ideations to family members.

The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom décor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? A. Rooms should contain extra-large windows with views of the street. B. Rooms should contain brightly colored walls with printed drapes. C. Rooms should be painted deep colors and located close to the nurse's station. D. Rooms should be painted with neutral colors and contain pale-colored accessories.

ANS: D Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the client's environment (low lighting, few people, simple décor, low noise levels). Anxiety levels rise in a stimulating environment. Neutral colors and pale accessories are most appropriate for a client experiencing mania. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? A. "Suicidal threats and gestures should be considered manipulative and/or attention-seeking." B. "Suicide is the act of a psychotic person." C. "All suicidal individuals are mentally ill." D. "Fifty to eighty percent of all people who kill themselves have a history of a previous attempt."

ANS: D It is a fact that between 50% and 80% of all people who kill themselves have a history of a previous attempt. All other answer choices are myths about suicide.

The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision? A. No previous admissions for major depressive disorder B. Vital signs stable; no psychosis noted C. Able to comply with medication regimen; able to problem-solve life issues D. Able to participate in a plan for safety; family agrees to constant observation

ANS: D Participation in a plan of safety and constant family observation will decrease the risk for self-harm. All other answer choices are not directly focused on suicide prevention and safety.

During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? A. Powerlessness R/T altered mood AEB client statements B. Risk for injury R/T altered mood AEB client statements C. Risk for suicide R/T altered mood AEB client statements D. Hopelessness R/T altered mood AEB client statements

ANS: D The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide a further evaluation of the client's suicidal ideations and intent would be necessary.

An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior.

ANS: D The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

ANS: D The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment

A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. "You've really been helpful. Can I count on you for continued support?" B. "I don't work out anymore." C. "I'm really glad I didn't go home. It would have been hard to come back." D. "I carry mace when I jog. It makes me feel safe and secure."

ANS: D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing reply? A. "Zyprexa in combination with Eskalith cures manic symptoms." B. "Zyprexa prevents extrapyramidal side effects." C. "Zyprexa ensures a good night's sleep." D. "Zyprexa calms hyperactivity until the Eskalith takes effect."

ANS: D The nurse should explain to the client's spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this client's crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6

ANS: D The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

ANS: D The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

ANS: D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

In planning care for a suicidal client, which correctly written outcome should be a nurse's first priority? A. The client will not physically harm self. B. The client will express hope for the future by day 3. C. The client will establish a trusting relationship with the nurse. D. The client will remain safe during the hospital stay.

ANS: D The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority. The "A" answer choice is incorrectly written. Correctly written outcomes must be client focused, measurable, realistic, and contain a time frame. Without a time frame, an outcome cannot be correctly evaluated.

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. "Treatment is compromised when clients can't sleep." B. "Treatment is compromised when irritability interferes with social interactions." C. "Treatment is compromised when clients have no insight into their problems." D. "Treatment is compromised when clients choose not to take their medications."

ANS: D The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications. Symptoms of bipolar disorder will reemerge if medication is stopped. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? A. "Why don't you consider doing volunteer work in a homeless shelter." B. "Let's discuss the negative aspects of your life." C. "Things will look better in the morning." D. "It sounds like you are feeling pretty hopeless."

ANS: D This statement verbalizes the client's implied feelings and allows him to validate and explore them.

4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the rape, because this may lead to further emotional trauma. B. Remain nonjudgmental while actively listening to the client's description of the violent rape event. C. Meet the client's self-care needs by assisting with showering and perineal care. D. Probe for further, detailed description of the rape event.

B The most appropriate nursing action is to remain nonjudgmental and actively listen to the client's description of the event. It is important to also communicate to the victim that he/she is safe and that it is not his/her fault. Nonjudgmental listening provides an avenue for catharsis, which contributes to the healing process.

14. A client diagnosed with an eating disorder experiences insomnia, nightmares, and panic attacks that occur before bedtime. She has never married or dated, and she lives alone. She states to a nurse, "My father has recently moved back to town." What should the nurse suspect? A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood physical abuse

B The nurse should suspect that this client may have a history of childhood incest. Adult survivors of incest are at risk for developing post-traumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

10. When questioned about bruises, a woman states, "It was an accident. My husband just had a bad day at work. He's being so gentle now and even brought me flowers. He's going to get a new job, so it won't happen again." This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

C The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid, next time, he will kill me." Which is the appropriate nursing response? A. "Leopards don't change their spots, and neither will he." B. "There are things you can do to prevent him from losing control." C. "Let's talk about your options so that you don't have to go home." D. "Why don't we call the police so that they can confront your husband with his behavior?"

C The most appropriate response by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions on their own without the nurse being the "rescuer." Imposing judgments and giving advice is nontherapeutic.

9. A client asks, "Why does a rapist use a weapon during the act of rape?" Which is the most appropriate nursing response? A. "To decrease the victimizer's insecurity." B. "To inflict physical harm with the weapon." C. "To terrorize and subdue the victim." D. "To mirror learned family behavior patterns related to weapons."

C The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

12. A survivor of rape presents in an emergency department crying, pacing, and cursing her attacker. A nurse should recognize these client actions as which behavioral defense? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction

C The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

5. A raped client answers a nurse's questions in a monotone voice with single words, appears calm, and exhibits a blunt affect. How should the nurse interpret this client's responses? A. The client may be lying about the incident. B. The client may be experiencing a silent rape reaction. C. The client may be demonstrating a controlled response pattern. D. The client may be having a compounded rape reaction.

C This client is most likely demonstrating a controlled response pattern. In the controlled response pattern, the client's feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying sobbing, smiling, restlessness, and tension.

11. Which information should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it. B. Research lawyers that can aid in divorce proceedings. C. File charges of assault and battery. D. Have ready access to the number of a safe house for battered women.

D The nurse should provide information about the accessibility of safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear.

2. A woman presents with a history of physical and emotional abuse in her intimate relationships. What should this information lead a nurse to suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman may be a victim of incest.

D The nurse should suspect that this client may be a victim of incest. Many women who are battered have low self-esteem and have feelings of guilt, anger, fear, and shame. Women in abusive relationships often grew up in an abusive home.

6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate response? A. "These clients don't know life any other way, and change is not an option until they have improved insight." B. "These clients have limited cognitive skills and few vocational abilities to be able to make it on their own." C. "These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation." D. "These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness."

D The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.