CHAPTER 15 MOOD DISORDERS

46. A nursing student is studying major depressive disorder. Which student statement indi- cates that learning has occurred? 1. "1% of the population is affected by depression yearly." 2. "2% to 5% of women experience depression during their lifetimes." 3. "1% to 3% of men become clinically depressed." 4. "Major depression is a leading cause of disability in the United States."

1. 10%, not 1%, of the population, or 19 million Americans, are affected by depression yearly. 2. 10% to 25%, not 2% to 5%, of women experience depression during their lifetimes. 3.During their lifetimes, 5% to 12%, not 1% to 3%, of men become clinically depressed. ✅ 4. Major depression is one of the leading causes of disability in the United States. This is not to be confused with an occasional bout with the "blues," a feeling of sadness or downheartedness. Such feelings are common among healthy individuals and are considered a normal response to everyday disappointments in life. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must understand the epi- demiology of major depressive disorder.

15. Which is the key to understanding if a child or adolescent is experiencing an underly- ing depressive disorder? 1. Irritability with authority. 2. Being uninterested in school. 3. A change in behaviors over a 2-week period. 4. Feeling insecure at a social gathering.

1. A child or adolescent expressing irritability toward authority figures reflects behavior that can be within the parameters of normal emotional development for this age group. 2. A child or adolescent being uninterested in school reflects behavior that can be within the parameters of normal emotional development for this age group. 3.✅ Change in behavior is an indicator that differentiates mood disorders from the typical stormy behaviors of adolescence. Depression can be a common manifestation of the stress and independence conflicts associated with the normal maturation process. Assessment of normal baseline behaviors would help the nurse recognize changes in behaviors that may indicate underlying depressive disorders. 4. A child or adolescent feeling insecure at social gatherings reflects behavior that can be within the parameters of normal emotional development for this age group. TEST-TAKING HINT: The test taker must recognize normal child and adolescent conduct to choose a behavior that is outside the norm for child and adolescent development.

18. A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first? 1. A client on one-to-one status because of active suicidal ideations. 2. A client pacing the hall and experiencing irritability and flight of ideas. 3. A client diagnosed with hypomania monopolizing time in the milieu. 4. A client with a history of mania who is to be discharged in the morning.

1. A client on one-on-one observation status is being monitored constantly by staff members and would not require immediate assessment. ✅ 2. Most assaultive behavior that occurs on an in-patient unit is preceded by a period of increasing hyperactivity. A client's behavior of pacing the halls and experiencing irritability should be considered emergent and warrant immediate attention. Because of these symptoms, this client would need to be assessed first. 3. Client behaviors that are experienced during hypomanic episodes are not as extreme as behaviors that may occur in manic episodes. The nurse may need to address the behavior of monopolizing time in the milieu, but this would be a less critical intervention. Compared with the other clients described, the nurse can delay this client's assessment. 4. When clients meet discharge criteria, acute symptoms have been resolved. Assessment of client needs is important for discharge planning, but compared with the other clients described, the nurse can delay this client's assessment. TEST-TAKING HINT: When deciding priority assessments, the test taker must look for the client with the most critical problem who can pose a safety risk to self or others. In this question, "1" would meet safety criteria, but because this client already is being monitored by staff, this answer choice would take lower priority.

57. A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client's lithium serum level would be which of the following? 1. 0.6 mEq/L. 2. 1.5 mEq/L. 3. 2.6 mEq/L. 4. 3.5 mEq/L.

1. A client with a lithium serum level of 0.6 mEq/L would not experience any nega- tive symptoms because this level indicates that the client's serum concentration is at the low end of normal. 2. A client with a lithium serum level of 1.5 mEq/L may experience blurred vision, ataxia, tinnitus, persistent nausea and vomit- ing, and severe diarrhea. The client's symp- toms described in the question do not support a lithium serum level of 1.5 mEq/L. ✅3. A client with a lithium serum level of 2.6 mEq/L may experience an excessive output of dilute urine, tremors, muscular irritability, psychomotor retardation, and mental confusion. The client's symptoms described in the question support a lithium serum level of 2.6 mEq/L. 4.A client with a lithium serum level of 3.5 mEq/L may experience impaired con- sciousness, nystagmus, seizures, coma, olig- uria or anuria, arrhythmias, and myocardial infarction. The client's symptoms described in the question do not support a lithium serum level of 3.5 mEq/L. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be aware of the symp- toms associated with various lithium serum levels.

29. A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R / T biochemical alterations. Based on this diagnosis, which outcome would be appropriate? 1. The client will not experience injury throughout the shift. 2. The client will interact appropriately with others by day 3. 3. The client will be compliant with prescribed medications. 4. The client will distinguish reality from delusions by day 6.

1. A client's being free of injury throughout a shift would be an appropriate outcome for the nursing diagnosis of risk for injury, not disturbed thought process. 2. A client's interacting appropriately by day 3 would be an appropriate outcome for the nursing diagnosis of impaired social interaction, not disturbed thought process. 3. A client's being compliant with prescribed medications would be an appropriate out- come for the nursing diagnosis of disturbed thought processes R/T biochemical alterations. Medications address the biochemical alterations that cause disturbed thought in clients diagnosed with bipolar I disorder. The reason this outcome is an incorrect choice is because it does not contain a timeframe and cannot be measured. ✅4. Distinguishing reality from delusions by day 6 is an appropriate outcome for the nursing diagnosis of disturbed thought processes R/T biochemical alterations. Altered thought processes have improved when the client can distinguish reality from delusions. TEST-TAKING HINT: To select the correct answer, the test taker must be able to pair the nursing diagnosis presented in the question with the correct client outcome. There always must be a correlation between the stated problem and the expectation for improvement.

42. A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation? 1. Join the milieu to assess the appropriateness of the laughter. 2. Redirect clients in the milieu to structured social activities, such as cards. 3. Privately discuss with the client the inappropriateness of provocative dress during hospitalization. 4. Administer PRN anti-anxiety medication to calm the client.

1. Although it is important for the nurse to gather any significant data related to client behaviors in the milieu, this nurse already has made the determination that the client is provocatively dressed. Dressing provocatively can precipitate sexual overtures that can be dangerous to the client and must be addressed immediately. 2. By redirecting clients to structured social activities, the nurse is not dealing with the assessed, critical problem of provocative dress. ✅ 3. Because dressing provocatively can precipitate sexual overtures that can be dangerous to the client, it is the priority of the nurse to discuss with the client the inappropriateness of this clothing choice. 4. When the nurse administers antianxiety medications in an attempt to calm the client, the nurse is ignoring the assessed critical problem of the client's provocative dress. TEST-TAKING HINT: The test taker should note that "1," "2," and "4" all address the observed behavior of potentially insignificant laughter in the milieu. Only "3" addresses the actual critical problem of provocative dress.

49. A nursing instructor is presenting statistics regarding suicide. Which student statement indicates that learning has occurred? 1. "Approximately 10,000 individuals in the United States commit suicide each year." 2. "Almost 95% of all individuals who commit or attempt suicide have a diagnosed mental disorder." 3. "Suicide is the eighth leading cause of death among young Americans 15 to 24 years old." 4. "Depressive disorders account for 70% of all individuals who commit or attempt suicide."

1. Approximately 30,000, not 10,000, individuals in the United States commit suicide each year. ✅2 Almost 95% of all individuals who commit or attempt suicide have a diagnosed men- tal disorder. Most suicides are associated with mood disorders. 3. Suicide is the third, not eighth, leading cause of death among young Americans 15 to 24 years old. Only accidents and homicides have a higher incidence in this age group. Suicide is the eighth leading cause of death among adult Americans. 4.Depressive disorders account for 80%, not 70%, of all individuals who commit or attempt suicide. TEST-TAKING HINT: The test taker must be aware of epidemiological factors about suicide to answer this question correctly.

14. Major depressive disorder would be most difficult to detect in which of the following clients? 1. A 5-year-old girl. 2. A 13-year-old boy. 3. A 25-year-old woman. 4. A 75-year-old man.

1. Assessment of depressive disorders in 5-year- old children would include evaluating the symptoms of being accident-prone, experi- encing phobias, and expressing excessive self- reproach for minor infractions. Compared with the other age groups presented, MDD would be less difficult to detect in childhood. ✅2. Assessment of depressive disorders in 13- year-old children would include feelings of sadness, loneliness, anxiety, and hopeless- ness. These symptoms may be perceived as normal emotional stresses of growing up. Many teens whose symptoms are attributed to the "normal adjustments" of adolescence, are not accurately diagnosed and do not get the help they need. 3. A 25-year-old woman is no longer faced with the developmental challenges of adolescence. Compared with the other age groups presented, MDD would be less difficult to detect in adulthood. 4. In elderly individuals, adaptive coping strate- gies may be seriously challenged by major stressors, such as financial problems, physical illness, changes in body functioning, increas- ing awareness of approaching death, and numerous losses. Because these situations are expected in this age group, MDD would be anticipated and more easily diagnosed. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be able to recognize that the normal developmental challenges faced during adolescence may mirror symptoms of depression, making diagnostic determinations difficult.

39. A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse's priority intervention? 1. Place the client on a one-to-one to avoid injury. 2. Ask the physician for a psychiatric consultation. 3. Assess vital signs, and complete physical assessment. 4. Reinforce relaxation techniques to decrease anxiety.

1. Before assuming the client's problem is psychological in nature and placing the client on a one-to-one observation, the nurse should rule out a physical cause for the symptoms presented. 2. Before assuming the client's problem is psychological in nature and requesting a psychiatric consultation, the nurse should rule out a physical cause for the symptoms presented. ✅3. The nurse first should assess vital signs and complete a physical assessment to rule out a physical cause for the symptoms presented. Many physical problems mani- fest in symptoms that seem to be caused by psychological problems. 4. By reinforcing relaxation techniques to decrease anxiety, the nurse has assumed, with- out sufficient assessment data, that the client's problems are caused by anxiety. Before making this assumption, the nurse should rule out a physical cause for the symptoms presented. TEST-TAKING HINT: The test taker must recognize that many physical problems manifest themselves in symptoms that, on the surface, look psycho- logical in nature. A nursing assessment should progress from initially gathering physiological data toward collecting psychological information.

60. Which medication would be classified as a tricyclic antidepressant? 1. Bupropion (Wellbutrin). 2. Mirtazapine (Remeron). 3. Citalopram (Celexa). 4. Nortriptyline (Pamelor).

1. Bupropion (Wellbutrin) is a heterocyclic, not tricyclic, antidepressant. This medication, also called Zyban, is used to assist with smok- ing cessation . 2. Mirtazapine (Remeron) is a heterocyclic, not tricyclic, antidepressant. 3. Citalopram (Celexa) is a selective serotonin reuptake inhibitor, not a tricyclic antidepressant. ✅4. Nortriptyline (Pamelor) is classified as a tricyclic antidepressant. Other tricyclic antidepressants include amitriptyline (Elavil), doxepin (Sinequan), and imipramine (Tofranil). TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be familiar with the various classes of antidepressant medications and the drugs within these classes.

56. A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms? 1. Amitriptyline (Elavil) and divalproex sodium (Depakote). 2. Verapamil (Calan) and topiramate (Topamax). 3. Lithium carbonate (Eskalith) and clonazepam (Klonopin). 4. Risperidone (Risperdal) and lamotrigine ).

1. Divalproex sodium (Depakote) is a mood stabilizer commonly prescribed to treat clients diagnosed with bipolar I disorder. Amitriptyline (Elavil), a tricyclic antidepres- sant, would not address the symptoms described in the question and may precipitate a manic episode in clients diagnosed with bipolar I disorder. 2. Both verapamil (Calan) and topiramate (Topamax) are used as mood stabilizers in the treatment of bipolar I disorder, but neither medication would address the auditory hallucinations exhibited by the client in the question. 3. Lithium carbonate (Eskalith) is a mood stabilizer commonly prescribed to treat clients diagnosed with bipolar I disorder. Clonazepam (Klonopin), an antianxiety med- ication, may treat agitation and anxiety, but would not address the auditory hallucinations experienced by the client. ✅4. Risperidone (Risperdal), an antipsy- chotic, directly addresses the auditory hallucinations experienced by the client. Lamotrigine (Lamictal), a mood stabilizer, would address the classic symptoms of bipolar I disorder. TEST-TAKING HINT: The test taker first must rec- ognize risperidone (Risperdal) as an antipsychot- ic and lamotrigine (Lamictal) as a mood stabiliz- er. Understanding the classification and action of these medications helps the test taker link them to the symptoms experienced by the client.

47. A client has a nursing diagnosis of dysfunctional grieving R / T loss of a job AEB inability to seek employment because of sad mood. Which would support a resolution of this client's problem? 1. The client reports an anxiety level of 2 out of 10 and denies suicidal ideations. 2. The client exhibits trusting behaviors toward the treatment team. 3. The client is noted to be in the denial stage of the grief process. 4. The client recognizes and accepts the role he or she played in the loss of the job.

1. Grieving clients may experience anxiety; however, the anxiety level described supports evidence of the resolution of client anxiety, not dysfunctional grieving. 2. It is important for a client to develop trust- ing relationships; however, the ability to trust is not evidence that supports the resolution of dysfunctional grieving. 3. A client in denial 2 years after a loss is evidence of a dysfunctional grieving problem, not of its resolution. ✅ 4. Accepting responsibility for the role played in a loss indicates that the client has moved forward in the grieving process and resolved the problem of dysfunctional grieving. TEST-TAKING HINT: To select the correct answer, the test taker must be able to pair the nursing diagnosis presented in the question with the correct evidence for resolution of the client problem. There always must be a correlation between the stated problem and the evaluation data

19. A nurse is planning to teach about appropriate coping skills. The nurse would expect which client to be at the highest level of readiness to participate in this instruction? 1. A newly admitted client with an anxiety level of 8/10 and racing thoughts. 2. A client admitted 6 days ago for a manic episode refusing to take medications. 3. A newly admitted client experiencing suicidal ideations with a plan to overdose. 4. A client admitted 6 days ago for suicidal ideations following a depressive episode.

1. High anxiety levels decrease the ability for this client to concentrate, and racing thoughts make focusing and learning difficult. Compared with the other clients described, this client would have a lower level of readiness to participate in instruction. 2. During a manic episode, cognition and perceptions become fragmented. Rapid thinking proceeds to racing and disjointed thoughts, making learning difficult. Because of non- compliance with medications, this client would still be experiencing manic symptoms. Compared with the other clients described, this client would have a lower level of readiness to participate in instruction. 3 .Because a newly admitted client experiencing suicidal ideations with a plan to overdose is in a crisis situation, focusing and learning would be difficult to accomplish. Compared with the other clients described, this client would have a lower level of readiness to participate in instruction. ✅ 4. A client admitted 6 days ago for suicidal ideations has begun to stabilize because of the treatment received during this time- frame. Compared with the other clients described, this client would have the highest level of readiness to participate in instruction. TEST-TAKING HINT: To answer this question correctly, it is important for the test taker to under- stand that symptoms of mania, anxiety, and crisis all affect a client's ability to learn.

4. Which statement about the development of bipolar disorder is from a biochemical perspective? 1. 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%. 2. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium. 3. Magnetic resonance imaging studies have revealed enlarged third ventricles, subcortical white matter, and periventricular hyperintensity in individuals diagnosed with bipolar disorder. 4. Twin studies have indicated a concordance rate among monozygotic twins of 60% to 80%.

1. Increased risk for the diagnosis of bipolar dis- order based on family history is evidence of a genetic, not biochemical, perspective in the development of the disease. ✅2. Alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium, is an example of a biochemical perspective in the development of bipolar disorder. 3. Enlarged third ventricles, subcortical white matter, and periventricular hyperintensity occur in individuals diagnosed with bipolar disorder. This theory is from a neuroanatomical, not biochemical, perspective in the development of the disease. 4. Twin studies support evidence that heredity plays a major role in the etiology of bipolar disorder. This theory is from a genetic, not biochemical, perspective in the development of the disease. TEST-TAKING HINT: The test taker needs to understand the various theories that are associat- ed with the development of bipolar disorders to answer this question correctly. Only "2" is a theory from a biochemical perspective.

36. A client diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize? 1. Empathize with the client about fears regarding ECT. 2. Monitor for any cardiac alterations to avoid possible negative outcomes. 3. Discuss with the client and family expected short-term memory loss. 4. Inform the client that injury related to induced seizure commonly occurs.

1. It is important to empathize with a client about fears related to ECT; however, this intervention would not be categorized as teaching. 2. It is important to monitor for any cardiac alterations during the ECT procedure to avoid possible cardiac complications; however, this intervention would not be categorized as teaching. ✅3. An expected and acceptable side effect of ECT is short-term memory loss. It is important for the nurse to teach the client and family members this information to avoid unnecessary anxiety about this symptom. 4. During ECT, the effects of induced seizure are mediated by the administration of muscle relaxant medications. This lowers the client's risk for injury. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must differentiate a teaching intervention from other interventions presented.

33. A client denying suicidal ideations comes into the emergency department complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first? 1. Request a psychiatric consultation. 2. Complete a thorough physical assessment including lab tests. 3. Remove all hazardous materials from the environment. 4. Place the client on a one-to-one observation.

1. It may be appropriate to request a psychiatric consultation for a client experiencing insomnia, irritability, anorexia, and depressed mood, but this determination would be made after ruling out physical problems that may cause these symptoms. ✅2. Numerous physical conditions can con- tribute to symptoms of insomnia, including irritability, anorexia, and depressed mood. It is important for the nurse to rule out these physical problems before assuming that the symptoms are psychological in nature. The nurse can do this by completing a thorough physical assessment including lab tests. 3. Because the client has denied suicidal ideations, it would be unnecessary at this time to remove all hazardous materials from the environment. 4. Because the client has denied suicidal ideations, it would be unnecessary at this time to place the client on a one-to-one observation. TEST-TAKING HINT: Client symptoms presented in the question determine the priority nursing intervention. Because this client has denied suicidal ideations, "3" and "4" can be eliminated immediately as priority interventions. Also, the nurse must never make the initial assumption that presented symptoms are psychological in nature before assessing for a physical cause.

44. A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R / T extreme hyperactivity. Which nursing intervention is appropriate? 1. Place the client in a room with another client experiencing similar symptoms. 2. Use PRN antipsychotic medications as ordered by the physician. 3. Discuss consequences of the client's behaviors with the client daily. 4. Reinforce previously learned coping skills to decrease agitation.

1. Placing a hyperactive client diagnosed with bipolar I disorder with another hyperactive client would only serve to increase hyperactivity in both clients. When a client is in a manic phase of the disorder, the best intervention is to reduce environmental stimuli, assign a private room, and keep lighting and noise level low. ✅2. A newly admitted client experiencing an extremely hyperactive episode as the result of bipolar I disorder would benefit from an antipsychotic medication to sedate the client quickly. Lithium carbon- ate (lithium) should be given concurrently for maintenance therapy and to prevent or diminish the intensity of subsequent manic episodes. 3. A client experiencing an extremely hyper- manic episode as the result of bipolar I disorder would be a difficult candidate for a meaningful interaction. This client also would have difficulty comprehending the cause and effect of behaviors. 4. Reinforcing previously learned coping skills with a client experiencing a hypermanic episode would increase, not decrease, agitation. This client is unable to focus on review of learned behaviors because of the distractibility inherent in mania. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand that a client experiencing a manic episode must be de- escalated before any teaching, confronting, or enforcing can occur.

34. A client diagnosed with major depressive disorder has a nursing diagnosis of low self- esteem R / T negative view of self. Which cognitive intervention by the nurse would be appropriate to deal with this client's problem? 1. Promote attendance in group therapy to assist client to socialize. 2. Teach assertiveness skills by role-playing situations. 3. Encourage the client to journal to uncover underlying feelings. 4. Focus on strengths and accomplishments to minimize failures.

1. Promoting attendance in group therapy to assist in socialization would be an interpersonal, not cognitive, intervention by the nurse. Interpersonal interventions focus on promoting appropriate interactions between individuals. 2. Teaching assertiveness skills by role-playing would be a behavioral, not cognitive, intervention by the nurse. Behavioral interventions focus on promoting appropriate behaviors by the use of rewards and deterrents. 3. Encouraging the client to journal to uncover underlying feelings would be an intrapersonal, not cognitive, intervention by the nurse. Intrapersonal interventions focus on discussions of feelings, internal conflicts, and developmental problems. ✅4. Focusing on strengths and accomplishments to minimize failures is a cognitive intervention by the nurse. Cognitive interventions focus on altering distortions of thoughts and negative thinking. TEST-TAKING HINT: To answer this question correctly, the test taker must recognize nursing interventions that use a cognitive approach. All other interventions presented may be appropriate to deal with client problems, but are not from a cognitive perspective.

23. A client diagnosed with major depressive disorder has been newly admitted to an in- patient psychiatric unit. The client has a history of two suicide attempts by hanging. Which nursing diagnosis takes priority? 1. Risk for violence directed at others R / T anger turned outward. 2. Social isolation R / T depressed mood. 3. Risk for suicide R / T history of attempts. 4. Hopelessness R / T multiple suicide attempts.

1. Risk for violence directed at others is an inappropriate nursing diagnosis for this client because no evidence is presented in the question that would indicate violence toward others. 2. Although social isolation R / T depressed mood is a common problem for clients diagnosed with major depression, no evidence is presented in the question that would indicate the client is isolating self. ✅3. Risk for suicide R / T history of attempts is a priority nursing diagnosis for a client who is diagnosed with major depression and has a history of two suicide attempts by hanging. A history of a suicide attempt increases a client's risk for future attempts. Because various means can be used to hang oneself, the client is at risk for accessing these means, even on an in- patient unit. These factors would cause the nurse to prioritize this safety concern. 4. Because of this client's history of suicide attempts, hopelessness is a problem for this client. However, compared with the nursing diagnoses presented, hopelessness would be prioritized lower than risk for suicide. After the nurse ensures the client's safety, hopeless- ness can be addressed. TEST-TAKING HINT: In choosing a priority diagnosis, the test taker must look for a client problem that needs immediate attention. In this question, if risk for suicide is not prioritized, the client may not be alive to deal with other problems.

20. A newly admitted client has been diagnosed with major depressive disorder. Which nursing diagnosis takes priority? 1. Social isolation R / T poor mood AEB refusing visits from family. 2. Self-care deficit R / T hopelessness AEB not taking a bath for 2 weeks. 3. Anxiety R / T hospitalization AEB anxiety rating of an 8/10. 4. Risk for self-directed violence R / T depressed mood.

1. Social isolation is defined as aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. Although a newly admitted client diagnosed with MDD may experience social isolation because of withdrawal behaviors, this problem is not life-threatening and is not the priority 2. Self-care deficit is defined as an impaired ability to perform or complete feeding, bathing/hygiene, dressing/grooming, or toileting activities. Although clients diagnosed with MDD experience self-care deficits related to poor self-esteem and low energy levels, this problem is not life-threatening and is not the priority. 3. Anxiety is defined as a vague uneasy feeling of discomfort or dread, accompanied by an autonomic response. Although clients diagnosed with MDD commonly experience anxiety, this problem is not life-threatening and is not the priority. ✅4. Risk for self-directed violence is the priori- ty diagnosis for a newly admitted client diagnosed with MDD. Risk for self-directed violence is defined as behaviors in which the individual demonstrates that he or she can be physically harmful to self. This is a life-threatening problem that requires immediate prioritization by the nurse. TEST-TAKING HINT: To answer this question correctly, the test taker needs to recognize the importance of prioritizing potentially life-threatening problems associated with the diagnosis of MDD.

27. Which client would the charge nurse assign to an agency nurse working on the in- patient psychiatric unit for the first time? 1. A client experiencing passive suicidal ideations with a past history of an attempt. 2. A client rating mood as 3/10 and attending but not participating in group therapy. 3. A client lying in bed all day long in a fetal position and refusing all meals. 4. A client admitted for the first time with a diagnosis of major depression.

1. The agency nurse working on an in-patient psychiatric unit for the first time may be unfamiliar with critical assessments related to suicide risk. A client with a history of a suicide attempt is at an increased risk for a future attempt. Compared with the other clients described, this client would require an assignment of a more experienced psychiatric nurse. ✅ 2. Although this client rates mood low, there is no indication of suicidal ideations, and the client is attending groups in the milieu. Because this client is observable in the milieu by all staff members, assignment to an agency nurse would be appropriate. 3. The agency nurse working on an in-patient psychiatric unit for the first time may be unfamiliar with critical assessments needed when the client is isolating self and being noncompliant with meals. This client is at risk for nutritional deficits and needs encouragement to participate actively in the plan of care. Compared with the other clients described, this client would require an assignment of a more experienced psychiatric nurse. 4. The agency nurse working on an in-patient psychiatric unit for the first time may be unfamiliar with the diagnostic criteria for major depression. Because this client is admitted for the first time, there is no history of past assessments or successful interventions. Therefore, it is critical that the nurse have an understanding of needed assessments and appropriate interventions to evaluate this client initially. TEST-TAKING HINT: In a question that requires a choice of delegation to inexperienced personnel, the test taker must look for the client who requires the least complicated nursing assessment and intervention and is at a low safety risk.

51. A nursing instructor is teaching about the psychosocial theory related to the develop- ment of bipolar disorder. Which student statement would indicate that learning has occurred? 1. "The credibility of psychosocial theories in the etiology of bipolar disorder has strengthened in recent years." 2. "Bipolar disorder is viewed as a purely genetic disorder." 3. "Following steroid, antidepressant, or amphetamine use, individuals can experience manic episodes." 4. "The etiology of bipolar disorder is unclear, but it is possible that biological and psychosocial factors are influential."

1. The credibility of psychosocial theories that deal with the etiology of bipolar disorder has weakened, not strengthened, in recent years. 2. The etiology of bipolar disorder is affected by genetic, biochemical, and physiological fac- tors. If bipolar disorders were purely genetic, there would be a 100% concordance rate among monozygotic twins. Research shows the concordance rate among monozygotic twins is only 60% to 80%. 3. Following steroid, antidepressant, or amphet- amine use, individuals can experience manic episodes. The response to these medications, which cause these symptoms, is physiological, not psychosocial. ✅4. The etiology of bipolar disorder is unclear; however, research evidence shows that biological and psychosocial factors are influential in the development of the disorder. TEST-TAKING HINT: The test taker needs to understand the various theories that are associat- ed with the development of bipolar disorders to answer this question correctly.

38. A client notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority? 1. Place the client on a one-to-one observation. 2. Determine if the client has a specific plan to commit suicide. 3. Assess for past history of suicide attempts. 4. Notify all staff members and place the client on suicide precautions.

1. To intervene by placing a client on a one-on- one observation before completing a full suicide risk assessment is premature. One-on- one observation may be too extreme an intervention to impose in this situation. Assessment is the first step in the nursing process. ✅ 2. Assessing a client's plan for suicide would give the nurse the information needed to intervene appropriately and therefore should be prioritized. 3. Although it is important to assess for a past history of suicide attempts, and this does place the client at an increased risk for suicide, a current plan indicates an immediate risk. 4. If the nurse notifies all staff members of a client's suicidal intentions and places the client on suicide precautions before a full suicide assessment, the nurse may be basing this intervention on inaccurate information. Suicide precautions may be necessary for clients experiencing suicidal ideations; how- ever, suicide precaution levels would be based on assessed client risk. TEST-TAKING HINT: To answer this question correctly, the test taker must recognize that the action of assessing a client is considered a nursing intervention. Gathering assessment data should take priority to intervene appropriately. When a client has a viable plan, the suicide risk is increased and requires immediate intervention.

53. A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disor- der. Which student statement indicates that learning has occurred? 1. "Clients diagnosed with bipolar II disorder experience a full syndrome of mania and have a history of symptoms of depression." 2. "Clients diagnosed with bipolar II disorder experience numerous episodes of hypo- mania and dysthymia for at least 2 years." 3. "Clients diagnosed with bipolar II disorder have mood disturbances that are directly associated with the physiological effects of a substance." 4. "Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania."

1. When a client experiences a full syndrome of mania with a history of symptoms of depres- sion, the client meets the criteria for bipolar I, not bipolar II, disorder. 2. When a client has experienced numerous episodes of hypomania and dysthymia for the last 2 years, the client meets the criteria for cyclothymia, not bipolar II disor- der. Cyclothymia is chronic in nature, and the symptoms experienced must be of insufficient severity or duration to meet the criteria for bipolar I or bipolar II disorder. 3. When disturbances of mood can be associated directly with the physiological effects of a substance, the client is likely to be diagnosed with a substance-induced mood disorder, not bipolar II disorder. ✅4.Recurrent bouts of depression and episodic occurrences of hypomania are diagnostic criteria for bipolar II disorder. Experiencing a full manic episode would indicate a diagnosis of bipolar I disorder and rule out a diagnosis of bipolar II disorder. TEST-TAKING HINT: The test taker must be able to distinguish the criteria for various mood disor- ders to answer this question correctly.

11. A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms? 1. "Rates mood as 4/10." 2. "Expresses thoughts of poor self-esteem during group." 3. "Became irritable and agitated on waking." 4. "Rates anxiety as 2/10 after receiving lorazepam (Ativan)."

1. When the client rates mood as 4 on a 10-point rating scale, the client is exhibiting affective, not behavioral, symptoms of depression. 2. When the client expresses thoughts of poor self-esteem, the client is exhibiting cognitive, not behavioral, symptoms of depression. ✅3. When the client becomes irritable and agitated on awakening, the client is exhibiting behavioral symptoms of depres- sion. Other behavioral symptoms include, but are not limited to, tearfulness, rest- lessness, slumped posture, and withdrawal. 4. When a client rates anxiety as 2/10 after receiving lorazepam (Ativan), the client is exhibiting affective, not behavioral, symptoms of depression. TEST-TAKING HINT: The test taker must be able to identify various categories of symptoms of depression, including affective, behavioral, cogni- tive, and physiological symptoms. This question is asking the test taker to distinguish a behavioral symptom from the other symptoms described.

8. Which charting entry most accurately documents a client's mood? 1. "The client expresses an elevation in mood." 2. "The client appears euthymic and is interacting with others." 3. "The client isolates self and is tearful most of the day." 4. "The client rates mood at a 2 out of 10."

1. When the nurse documents, "The client expresses an elevation in mood," the nurse is not providing objective, measurable data. Baseline information regarding mood would be needed to compare any verbalization of mood elevation. 2. Euthymia is a description of a normal range of mood. Mood is a subjective symptom that needs to be assessed from the client's perspective. When the nurse states, "The client appears euthymic," without validation from the client, the nurse has assumed assessment data that may be inaccurate 3..It is important for the nurse to document client behaviors that may indicate changes in mood, but because mood is a subjective symptom that needs to be assessed from the client's perspective, the nurse may be misinterpreting observations. For example, tears can represent a range of multiple emotional feelings varying from sadness to extreme happiness. ✅4. The use of a mood scale objectifies the subjective symptom of mood as a pain scale objectifies the subjective symptom of pain. The use of scales is the most accu- rate way to assess subjective data. TEST-TAKING HINT: In a question that requires a charting entry, the test taker must understand that nursing documentation should avoid assumptions and be based on objective data.

17. Which nursing charting entry is documentation of a behavioral symptom of mania? 1. "Thoughts fragmented, flight of ideas noted." 2. "Mood euphoric and expansive. Rates mood a 10/10." 3. "Pacing halls throughout the day. Exhibits poor impulse control." 4. "Easily distracted, unable to focus on goals."

1. When the nurse documents, "Thoughts frag- mented, flight of ideas noted," the nurse is charting a cognitive, not behavioral, symptom of mania. 2. When the nurse documents, "Mood euphoric and expansive. Rates mood a 10/10," the nurse is charting an affective, not behavioral, symptom of mania. ✅3. When the nurse documents, "Pacing halls throughout the day. Exhibits poor impulse control," the nurse is charting a behavioral symptom of mania. Psychomotor activities and uninhibited social and sexual behav- iors are classified as behavioral symptoms. 4. When the nurse documents, "Easily distracted, unable to focus on goals," the nurse is charting a cognitive, not behavioral, symptom of mania. TEST-TAKING HINT: The test taker must be able to differentiate the symptoms of mania as affective, cognitive, psychomotor, and behavioral to answer this question correctly.

24. A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority? 1. Altered thought processes R / T biochemical alterations. 2. Social isolation R / T grandiosity. 3. Disturbed sleep patterns R / T agitation. 4. Risk for violence: self-directed R / T depressive symptoms.

1.Altered thought processes is defined as a state in which an individual experiences an alteration in cognitive operations and activities. Nothing is presented in the question that would indicate this client is experiencing a disturbed thought process. Clients diagnosed with bipolar I disorder, not cyclothymia, may experience disturbed thought processes during manic episodes. 2. Social isolation is defined as aloneness experienced by the individual and perceived as imposed by others and as a negative and threatened state. Nothing is presented in the question that would indicate this client is experiencing social isolation. ✅3. Disturbed sleep patterns is defined as a time-limited disruption of sleep amount and quality. Because the client is sleeping only 2 hours a night, the client is meeting the defining characteristics of the nursing diagnosis of disturbed sleep patterns. This sleep problem is usually due to excessive hyperactivity and agitation. 4. Risk for violence: self-directed is defined as behaviors in which an individual demon- strates that he or she can be physically, emotionally, or sexually harmful to self. Nothing is presented in the question that would indicate this client is experiencing risk for violence, self-directed. TEST-TAKING HINT: To select the correct answer, the test taker must be able to correlate the client symptoms presented in the question with the nursing diagnosis that describes the client prob- lem exhibited by these symptoms.

48. A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders? 1. "When clients experience loss, they learn that it is inevitable and become hopeless and helpless." 2. "There are alterations in the neurochemicals, such as serotonin, which cause the client's symptoms." 3. "Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms." 4. "There is a genetic component affecting the development of mood disorders."

1.Learning theorists believe that learned helplessness predisposes individuals to depression by imposing a feeling of lack of control over their life situations. They become depressed because they feel helpless; they have learned whatever they do is futile. However, this theory is only one of the possible causes of mood disorders. 2.Neurobiological theorists believe that there are alterations in the neurochemicals, such as serotonin, which cause mood disorder symptoms. However, this theory is only one of the possible causes of mood disorders. ✅3.When the student states that there is sup- port for multiple causations related to an individual's susceptibility to mood symptoms, the student understands the content presented about the etiology of mood disorders. 4. Genetic theorists believe there is a strong genetic component affecting the development of mood disorders. However, this theory is only one of the possible causes of mood dis- orders. TEST-TAKING HINT: All answers presented are possible theories for the cause of mood disor- ders. To choose the correct answer, the test taker must understand that no one theory has been accepted as a definitive cause of mood disorders.

3. During an intake assessment, which client statement is evidence of the etiology of major depressive disorder from an object-loss theory perspective? 1. "I am so angry all the time and seem to take it out on myself." 2. "My grandmother and great-grandfather also had depression." 3. "I just don't think my life is ever going to get better. I can't do anything right." 4. "I don't know about my biological family; I was in foster care as an infant."

1.When the client expresses self-anger, it is a reflection of the psychoanalytic, not object- loss theory, perspective of the etiology of major depressive disorder (MDD). Freud describes depression as anger turned inward. 2. When clients indicate a family history of mood disorders, it is a reflection of the genetic, not object-loss theory, perspective of the eti- ology of MDD. Research has indicated a genetic link in the transmission of mood disorders. 3. When a client indicates cognitive distortions, it is a reflection of the cognitive, not object- loss theory, perspective of the etiology of MDD. Cognitive theorists believe that depression is a product of negative thinking. ✅4. Object-loss theorists suggest that depressive illness occurs as a result of being abandoned by or otherwise separated from a significant other during the first 6 months of life. The client in the question experienced parental abandonment, and according to object loss theory, this loss has led to the diagnosis of MDD. TEST-TAKING HINT: The test taker needs to under- stand the various theories that are associated with the development of mood disorders to answer this question correctly.

50. Aclient diagnosed with major depressive disorder has an outcome that states, "Theclient will verbalize a measure of hope about future by day 3." Which client statement indicates this outcome was successful? 1. "I don't want to die because it would hurt my family." 2. "I need to go to group and get out of this room." 3. "I think I am going to talk to my boss about conflicts at work." 4. "I thank you for your compassionate care."

1.When the client states that the only reason to stay alive is to avoid hurting family, the client is focused on the needs of others rather than valuing self. This lack of self-value indicates continued hopelessness. 2. Although it is encouraging when clients attend group, this client's statement does not indicate a successful outcome as it relates to an increase in hope for the future. ✅3. When the client begins to plan how to deal with conflicts at work, the client is focusing on a hopeful future. This indi- cates that the outcome of verbalizing a measure of hope about the future by day 3 has been successful. 4. Although it is encouraging that the client can recognize and appreciate the compassionate care of the staff, this statement does not indi- cate a successful outcome as it relates to an increase in hope for the future TEST-TAKING HINT: To select the correct answer, the test taker must be able to pair the outcome presented in the question with the client state- ment that reflects the successful completion of this outcome.

16. At 1 AM, the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. What would be the nurse's most therapeutic response? A) "Go to the day room and wait while I call your psychiatrist." B)" Don't be unreasonable. I can't call the psychiatrist at this time of night." C) "I can't call the psychiatrist now, but you and I can talk about your request for a pass." D) "You must really be upset to want a pass immediately; I'll give you some medication."

ANS:C Feedback: This response states a limit on an unreasonable request while providing the opportunity to discuss the request. Answer choices A, B, and D are not therapeutic.

13. A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time? A) Accompany the client to his or her room to get dressed. B) Put the client in seclusion for his or her own protection. C) Tell other clients to ignore the behavior because it is harmless. D) Tell the client that the behaviors have to stop right now.

Ans: A Feedback: Redirecting the client to appropriate behavior without confrontation is most effective. Seclusion is not an appropriate intervention for this situation. Ignoring the behavior is not indicated. The client is in the manic phase; telling him or her to stop the behavior may make the behaviors escalate.

6. A client is admitted for major depression. What should the nurse expect to find during assessment? A) Anhedonia, feelings of worthlessness, and difficulty focusing B) Depressed mood, guilt, and pressured speech C) Changes in sleep pattern, tired, and grandiose mood D) Difficulty focusing, feelings of helplessness, and flight of ideas

Ans: A Feedback: Symptoms of major depressive disorder include depressed mood; anhedonism (decreased attention to and enjoyment from previously pleasurable activities); unintentional weight change of 5% or more in a month; change in sleep pattern; agitation or psychomotor retardation; tiredness; worthlessness or guilt inappropriate to the situation (possibly delusional); difficulty thinking, focusing, or making decisions; or hopelessness, helplessness, and/or suicidal ideation. Grandiose mood, pressured speech, and flight of ideas are associated with mania.

5. A concerned family member tells the nurse, ìI am concerned about my brother. He has been acting very different lately.î Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the brother has bipolar disorder? A) Taking unnecessary risks B) Sleeping more C) Intense focus D) Showing low self-esteem

Ans: A Feedback: The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments.

12. A client who is manic states, "What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?î Which would be the most appropriate response by the nurse? A) "Please slow down. I'm not sure what you need first." B) "You will have to be quiet and have breakfast after the doctor comes." C) "Are you hungry?" D) "Your thoughts seem to be racing this morning."

Ans: A Feedback: The speech of manic clients may be pressured: rapid, circumstantial, rhyming, noisy, or intrusive with flights of ideas. The nurse must keep channels of communication open with clients, regardless of speech patterns. The nurse can say, "Please speak more slowly. I'm having trouble following you." This puts the responsibility for the communication difficulty on the nurse rather than on the client.

14. The client with mania attempts to hit the nurse. Which is the best response by the nurse? A) "Do not swing at me again. If you cannot control yourself, we will help you." B) "If you do that one more time, you will be put in seclusion immediately." C) "Stop that. I didn't do anything to provoke an attack." D) "Why do you continue that kind of behavior? You know I won't let you do it."

Ans: A Feedback: This response firmly states behavioral expectations and lets the client know his behavior will be safely controlled if he is unable to do so. The other choices are not appropriate responses to this situation.

18. A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first? A) Decrease the client's environmental stimuli. B) Give the client feedback about his behavior. C) Introduce the client to other staff on the unit. D) Tell the client about hospital rules and policies.

Ans: A Feedback: When the client is agitated, decreasing stimuli is the priority. Answer choices A, B, and C are not priority interventions.

9. A client who is depressed begins to cry and states, ìI'm just really sick of feeling this way. Nothing ever seems to go right in my life.î Which would be the most appropriate response by the nurse? A) "Don't cry. Try to look at the positive side of things." B) "You are feeling really sad right now. It's a hard time." C) "Hang in there. Your medication will start helping in a few days." D) "Nothing ever goes right?"

Ans: B Feedback: Do not cut off interactions with cheerful remarks or platitudes. Do not belittle the client's feelings. Accept the client's verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger). Allow (and encourage) the client to cry. It is important that the nurse does not attempt to ìfixî the client's difficulties

19. The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which would be the most therapeutic nursing intervention? A) Move to another chair closer to the client and say, "The staff is here to help you." B) Move to a chair a little further away and say, "We can just sit together quietly." C) Remain in place and say, "How are you feeling today?" D) Say, "I'll visit with you a little later," and leave the client alone for a while.

Ans: B Feedback: Moving away gives the client more personal space; staying with the client indicates acceptance and genuine interest. It is not necessary for the nurse to talk to the client the entire time; rather, silence can convey that clients are worthwhile even if they are not interacting.

17. A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale? A) As soon as lunch is over, the client will calm down. B) Other clients need to be protected from the intrusive behavior. C) The client's behavior is not an imminent threat to anyone's physical safety. D) The client needs food and fluids in any way possible.

Ans: B Feedback: The nurse must set limits on this intrusive behavior because other clients have the right to be protected. The client is in the manic phase; the client may not calm down after lunch. The behavior could be an imminent threat to individual safety for many reasons, infection control included. The client's need for food and fluids does not supersede any of the other clients' needs for food and fluids.

3. Which statements about the etiology of bipolar disorder do most psychoanalytical theories subscribe to? Select all that apply. A) Norepinephrine levels may be increased in mania. B) Manic episodes are a defense against underlying depression. C) Acetylcholine seems to be implicated in mania. D) The id takes over the ego and acts as an undisciplined hedonistic being (child).

Ans: B, D Feedback: Most psychoanalytic theories of mania view manic episodes as a ìdefenseî against underlying depression, with the id taking over the ego and acting as an undisciplined hedonistic being (child). Norepinephrine levels may be increased in mania, and acetylcholine seems to be implicated in mania, but these are neurochemical theories.

4. Which variables represent the highest risk for developing major depressive disorder? Select all that apply. A) Male gender B) Mood disorder in first-degree relatives C) Substance abuse D) Divorced E) Older adult

Ans: B, D Feedback: Major depression is twice as common in women and has a 1.5 to 3 times greater incidence in first-degree relatives than in the general population. Incidence of depression decreases with age in women and increases with age in men. Single and divorced people have the highest incidence. Depression in prepubertal boys and girls occurs at an equal rate.

1. Which best explains the neurochemical processes responsible for depression? A) Increased activity of dopamine B) Decreased glucocorticoid activity C) Decreased serotonin and norepinephrine activity D) Potentiating of the kindling process

Ans: C Feedback: Deficits of serotonin, its precursor tryptophan, or a metabolite (5-hydroxyindole acetic acid, or 5-HIAA) of serotonin found in the blood or cerebrospinal fluid occur in people with depression. Norepinephrine levels may be deficient in depression and increased in mania. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression. Kindling is the process by which seizure activity in a specific area of the brain is initially stimulated.

11. Which meal would the nurse provide to best meet the nutritional needs of a client who is manic? A) Peanut butter sandwich, chips, cola B) Fried chicken, mashed potatoes, milk C) Ham sandwich, cheese slices, milk D) Spaghetti, garlic bread, salad, tea

Ans: C Feedback: Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible.

15. During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse? A) "Do you think you could sit still for a few minutes so we can talk?" B) "How are you ever going to get any rest if you keep that music on?" C) "Let's go to the conference room and talk for a while." D) "Turn the radio down so we can hear ourselves talk."

Ans: C Feedback: Redirecting the client to a quieter, smaller room will decrease external stimuli and promote calmness, so the client will eventually rest and sleep.

8. The nurse is planning care for a client with major depression. Which is an appropriate expected outcome? A) The client will avoid causing harm to others. B) The client will be free from stress. C) The client will independently carry out activities of daily living. D) The client will not experience agitation.

Ans: C Feedback: Expected outcomes for the depressed client include the following: The client will not injure himself or herself. The client will independently carry out activities of daily living (showering, changing clothing, grooming). The client will establish a balance of rest, sleep, and activity. The client will establish a balance of adequate nutrition, hydration, and elimination. The client will evaluate self-attributes realistically. The client will socialize with staff, peers, and family/friends. The client will return to occupation or school activities. The client will comply with the antidepressant regimen. The client will verbalize symptoms of a recurrence. Avoiding agitation and harm to others are outcomes more appropriate for a client with mania. It is unrealistic to be completely free from stress.

10. A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior? A) Administering a sedative that has been prescribed to be used PRN. B) Insisting the client take a ìtime-outî in his room C) Clearing the area of all other clients D) Setting limits on aggressive and intimidating behavior

Ans: D Feedback: Because of the safety risks that clients in the manic phase take, safety plays a primary role in care, followed by issues related to self-esteem and socialization. It is necessary to set limits when they cannot set limits on themselves. Giving the client the opportunity to exercise self-control is most therapeutic. If the client cannot control his or her behavior, then more restrictive measures can be taken, such as room restriction or sedation. Clearing the area is not necessary during limit setting and may cause excessive panic on the part of other clients. When setting limits, it is important to clearly identify the unacceptable behavior and the expected, appropriate behavior. All staff must consistently set and enforce limits for those limits to be effective.

2. Which is a freudian explanation of the etiology of depression? A) Depression is a reaction to a distressing life experience. B) Depression results from being raised by rejecting or unloving parents. C) Depression results from cognitive distortions. D) Depression is anger turned inward.

Ans: D Feedback: Freud looked at the self-depreciation of people with depression and attributed that self- reproach to anger turned inward related to either a real or perceived loss. Meyer viewed depression as a reaction to a distressing life experience such as an event with psychic causality. Horney believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness. Beck saw depression as resulting from specific cognitive distortions in susceptible people.

7. A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm? A) Immediately after a family visit B) On the anniversary of significant life events in the client's life C) During the first few days after admission D) Approximately 2 weeks after starting antidepressant medication

Ans: D Feedback: Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide.

20. A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate? A) Allowing the client to direct her participation at her own pace B) Giving the client several choices of projects, so she can choose her favorite C) Staying away from the client during the session to encourage free expression D) Structuring the activity to facilitate completion of one specific task

Ans: D Feedback: The client needs to experience success in the group but is unlikely to do that independently. The other choices would not be appropriate actions for the client who is lethargic and apathetic.

26. A client admitted with major depressive disorder has a nursing diagnosis of ineffective sleep pattern R / T aches and pains. Which is an appropriate short-term outcome for this client? 1. The client will express feeling rested on awakening. 2. The client will rate pain level at or below a 4/10. 3. The client will sleep 6 to 8 hours at night by day 5. 4. The client will maintain a steady sleep pattern while hospitalized.

Any sleep pattern outcome assessment must be based on the client's normal sleep pattern base- line .1. The outcome of feeling rested on awakening is appropriate for the nursing diagnosis of ineffective sleep pattern; however, this out- come cannot be measured because it does not include a timeframe. 2. Because pain is the cause of this client's ineffective sleep pattern, this outcome can be appropriate for this nursing diagnosis; however, this outcome cannot be measured because it does not include a timeframe. 3. ✅ The appropriate short-term outcome for the nursing diagnosis of ineffective sleep pattern R/T aches and pains is to expect the client to sleep 6 to 8 hours a night by day 5. This outcome is client specific, realistic, and measurable, and includes a timeframe. 4. The problem with this outcome relates to inclusion of the term "steady sleep pattern." This term is abstract and can be interpreted in various ways and would not be measured consistently. TEST-TAKING HINT: To answer this question, the test taker must recognize a correctly written out- come for the stated nursing diagnosis. Outcomes always must be client-specific, realistic, and measurable, and include a timeframe.

5. Which statement describes a major difference between a client diagnosed with major depressive disorder and a client diagnosed with dysthymic disorder? 1. A client diagnosed with dysthymic disorder is at higher risk for suicide. 2. A client diagnosed with dysthymic disorder may experience psychotic features. 3. A client diagnosed with dysthymic disorder experiences excessive guilt. 4. A client diagnosed with dysthymic disorder has symptoms for at least 2 years.

Characteristics of dysthymic disorder are similar to, if not milder than, the characteristics ascribed to major depressive disorder (MDD). 1. Clients diagnosed with dysthymic disorder and MDD are at equally high risk for suicide. 2. A client diagnosed with MDD, not dysthymic disorder, may experience psychotic features. 3. A client diagnosed with dysthymic disorder may experience hopelessness, not excessive guilt. Clients diagnosed with MDD may experience excessive guilt and worthlessness. ✅ 4. An individual suspected to have dysthymic disorder needs to experience symptoms for at least 2 years before a diagnosis can be made. The essential feature is a chronically depressed mood (or possibly an irritable mood in children and adolescents) for most of the day, more days than not, for at least 2 years (1 year for children and adolescents). Clients with a diagnosis of MDD show impaired social and occupational functioning that has existed for at least 2 weeks. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand the chronic nature of dysthymic disorder, which dif- ferentiates this diagnosis from MDD.

41. A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client's a nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client? 1. Chicken fingers and French fries. 2. Grilled chicken and a baked potato. 3. Spaghetti and meatballs. 4. Chili and crackers.

Clients experiencing mania have excessive psychomotor activity that leads to an inability to sit still long enough to eat. Increased nutritional intake is necessary because of a high metabolic rate. ✅1. Chicken fingers and French fries are finger foods, which the client would be able to eat during increased psychomotor activity, such as pacing. Because these foods are high in caloric value, they also meet the client's increased nutritional needs. 2. Although grilled chicken and a baked potato would meet the client's increased nutritional needs, the baked potato is not a finger food and would be difficult for the client to eat during periods of hyperactivity .3. Although spaghetti and meatballs would meet the client's increased nutritional needs, this dinner would be difficult for the client to eat during periods of hyperactivity. 4. Although chili and crackers would meet the client's increased nutritional needs, this dinner would be difficult for the client to eat during periods of hyperactivity. TEST-TAKING HINT: To answer this question correctly, the test taker must understand that the symptom of hyperactivity during a manic episode affects the client's ability to meet nutritional needs. The test taker should look for easily portable foods with high caloric value to deter- mine the most appropriate meal for this client.

31. A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R / T egocentrism. Which short-term outcome is an appropriate expectation for this client problem? 1. The client will have an appropriate one-on-one interaction with a peer by day 4. 2. The client will exchange personal information with peers at lunchtime. 3. The client will verbalize the desire to interact with peers by day 2. 4. The client will initiate an appropriate social relationship with a peer.

Egocentrism is defined as viewing everything in relation to self, or self-centeredness. ✅ 1. A client's having an appropriate one-on- one interaction with a peer is a successful outcome for the nursing diagnosis of impaired social interaction. The test taker should note that this outcome is specific, client-centered, positive, realistic, and measurable, and includes a timeframe. Exchanging personal information with peers at lunchtime is an appropriate outcome for the nursing diagnosis of impaired social inter- actions R / T egocentrism. 2. Exchanging information with other clients indicates interest in others, which shows a decrease in egocentrism. However, this outcome does not contain a timeframe and so cannot be measured. 3. Although verbalizing a desire to interact with peers is an appropriate short-term outcome, this outcome addresses the nursing diagnosis of social isolation, not impaired social inter- action. 4. Initiating an appropriate social relationship with a peer is an outcome related to the nursing diagnosis of impaired social interaction; TEST-TAKING HINT: To answer this question correctly, the test taker needs to know the components of a correctly written outcome. Outcomes need to be specific, client-centered, realistic, positive, and measurable, and include a timeframe.

7. A client plans and follows through with the wake and burial of a child lost in an auto- mobile accident. Using Engel's model of normal grief response, in which stage would this client fall? 1. Resolution of the loss. 2. Recovery. 3. Restitution. 4. Developing awareness.

Engel's model consists of five stages of grief, including shock and disbelief, developing aware- ness, restitution, resolution of the loss, and recovery. 1. The client in the question is exhibiting signs associated with Engel's stage of restitution, not resolution of the loss. Resolution of the loss is the fourth stage of Engel's model of the normal grief response. 2. This stage is characterized by a preoccupation with the loss in which the deceased is idealized. The client in the question is exhibiting signs associated with Engel's stage of restitution, not recovery. Recovery is the fifth stage of Engel's model of the normal grief response. This stage is characterized by the individual's ability to continue with life. ✅3. The client in the question is exhibiting signs associated with Engel's stage of restitution. Restitution is the third stage of Engel's model of the normal grief response. In this stage, the various rituals associated with loss within a culture are performed. Examples include funerals, wakes, special attire, a gathering of friends and family, and religious practices customary to the spiritual beliefs of the bereaved. 4. The client in the question is exhibiting signs associated with the stage of restitution, not developing awareness. Developing awareness is the second stage of Engel's model of the normal grief response. This stage begins within minutes to hours of the loss. Behaviors associated with this stage include excessive crying and regression to the state of helpless- ness and a childlike manner. TEST-TAKING HINT: The test taker must be aware of the behaviors exhibited in the stages of Engel's grief model to answer this question correctly.

21. A client's outcome states, "The client will make a plan to take control of one life situ- ation by discharge." Which nursing diagnosis documents the client's problem that this outcome addresses? 1. Impaired social interaction. 2. Powerlessness. 3. Knowledge deficit. 4. Dysfunctional grieving.

Impaired social interaction is defined as the state in which the individual participates in an insufficient or excessive quantity or ineffective quality of social exchange. This nursing diagnosis does not address the outcome presented in the question. ✅ 2. Powerlessness is defined as the perception that one's own action would not significantly affect an outcome—a perceived lack of control over a current situation or immediate happening. Because the client outcome presented in the question addresses the lack of control over life situations, the nursing diagnosis of powerlessness documents this client's problem 3.Knowledge deficit is defined as the lack of specific information necessary for the client to make informed choices regarding condition, therapies, and treatment plan. This nursing diagnosis does not address the out- come presented in the question. 4. Dysfunctional grieving is defined as extended, unsuccessful use of intellectual and emotional responses by which individuals attempt to work through the process of modifying self- concept based on the perceptions of loss. This nursing diagnosis does not address the outcome presented in the question. TEST-TAKING HINT: To select the correct answer, the test taker must be able to pair the outcome presented in the question with the nursing diag- nosis that documents the client problem.

12. Which symptom is an example of physiological alterations exhibited by clients diagnosed with moderate depression? 1. Decreased libido. 2. Difficulty concentrating. 3. Slumped posture. 4. Helplessness.

Moderate level of depression represents more problematic disturbances than mild depression. ✅1. Decreased libido is a physiological alter- ation exhibited by clients diagnosed with moderate depression. 2. Difficulty concentrating is a cognitive, not physiological, alteration exhibited by clients diagnosed with moderate depression. 3. Slumped posture is a behavioral, not physio- logical, alteration exhibited by clients diag- nosed with moderate depression. 4. Helplessness is an affective, not physiological, alteration exhibited by clients diagnosed with moderate depression. TEST-TAKING HINT: The test taker must be able to identify various categories of depressive symptoms, including affective, behavioral, cognitive, and physiological symptoms. This question is asking the test taker to distinguish physiological symptoms from other symptoms described.

55. A client diagnosed with major depressive disorder is prescribed phenelzine (Nardil). Which teaching should the nurse prioritize? 1. Remind the client that the medication takes 4 to 6 weeks to take full effect. 2. Instruct the client and family about the many food-drug and drug-drug interactions. 3. Teach the client about the possible sexual side effects and insomnia that can occur. 4. Educate the client about the need to take the medication even after symptoms have improved.

Phenelzine (Nardil), an antidepressant, is cate- gorized as a monoamine oxidase inhibitor (MAOI). 1. It is important for the nurse to teach a client who has been prescribed phenelzine that this medication takes 4 to 6 weeks to take full effect. Compared with the other answer choices, this teaching topic is not prioritized. ✅2. Because there are numerous drug-food and drug-drug interactions that may precipitate a hypertensive crisis during treatment with MAOIs, it is critical that the nurse prioritize this teaching. 3. It is important for the nurse to teach a client who has been prescribed phenelzine that possible sexual side effects and insomnia can occur with the use of this drug. However, these symptoms are not as severe as a hypertensive crisis, and so compared with the other answer choices, this teaching topic is not prioritized. 4. It is important for the nurse to educate the client about consistently taking the prescribed medications, even after improvement of symptoms. However, compared with the other answer choices, this teaching topic is not prioritized TEST-TAKING HINT: To answer this question cor- rectly, the test taker must be aware that there are many special considerations related to the use of MAOIs. Understanding these considerations assists the test taker to prioritize client teaching needs.

59. Which symptoms would the nurse expect to assess in a client suspected to have sero- tonin syndrome? 1. Alterations in mental status, restlessness, tachycardia, labile blood pressure, and diaphoresis. 2. Hypomania, akathisia, cardiac arrhythmias, and panic attacks. 3. Dizziness, lethargy, headache, and nausea. 4. Orthostatic hypotension, urinary retention, constipation, and blurred vision.

Serotonin syndrome occurs when two drugs used concurrently potentiate serotoninergic neu- rotransmission. ✅1. Alterations in mental status, restlessness, tachycardia, labile blood pressure, and diaphoresis all are symptoms of serotonin syndrome. If this syndrome were suspect- ed, the offending agent would be discon- tinued immediately. 2. Hypomania, akathisia, cardiac arrhythmias, and panic attacks all are symptoms associated with discontinuation syndrome from tricyclic antidepressants, not serotonin syndrome. Discontinuation syndrome occurs with the abrupt discontinuation of any class of antide- pressants. 3. Dizziness, lethargy, headache, and nausea are symptoms associated with discontinuation syndrome from selective serotonin reup- take inhibitors, not serotonin syndrome. Discontinuation syndrome occurs with the abrupt discontinuation of any class of antide- pressants. 4. Orthostatic hypotension, urinary retention, constipation, and blurred vision are side effects associated with the use of tricyclics and heterocyclics, not symptoms of serotonin syndrome. TEST-TAKING HINT: The test taker must be able to differentiate the symptoms of discontinuation syndrome, the symptoms of serotonin syndrome, and the side effects associated with the use of antidepressants to answer this question correctly.

58. A client diagnosed with major depressive disorder is newly prescribed sertraline (Zoloft). Which of the following teaching points would the nurse review with the client? Select all that apply. 1. Monitor the client for suicidal ideations related to depressed mood. 2. Discuss the need to take medications, even when symptoms improve. 3. Instruct the client about the risks of abruptly stopping the medication. 4. Alert the client to the risks of dry mouth, sedation, nausea, and sexual side effects. 5. Remind the client that the medication's full effect does not occur for 4 to 6 weeks.

Sertraline (Zoloft), an antidepressant, is classi- fied as a selective serotonin reuptake inhibitor (SSRI). 1. Because of the numerous suicides associated with mood disorders, it is important to monitor this client for suicidal ideations related to depressed mood. However, this is a client assessment and not a teaching intervention. ✅2. Discussing the need for medication com- pliance, even when symptoms improve, is a teaching point that the nurse would need to review with a client who is newly prescribed sertraline. ✅3. Instructing the client about the risk for discontinuation syndrome is a teaching point that the nurse would need to review with a client who is newly prescribed sertraline. ✅4. Alerting the client to the risks of dry mouth, sedation, nausea, and sexual side effects is a teaching point that the nurse would need to review with a client who is newly prescribed sertraline. ✅5. Reminding the client that sertraline's full effect does not occur for 4 to 6 weeks is a teaching point that the nurse would need to review with a client who is newly pre- scribed sertraline. TEST-TAKING HINT: The test taker first must recognize sertraline as an SSRI. Knowing the classification of this drug would provide general medication information, rather than having to remember specific information about each SSRI.

13. Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression? 1. Apathy. 2. Somatic delusion. 3. Difficulty falling asleep. 4. Social isolation.

Severe depression is characterized by an intensi- fication of the symptoms described for moderate depression. ✅1. Apathy is defined as indifference, insensi- bility, and lack of emotion. Apathy is an affective alteration exhibited by clients diagnosed with severe depression. 2. Somatic delusion is a cognitive, not affective, alteration exhibited by clients diagnosed with severe depression. 3. Difficulty falling asleep is a physiological, not affective, alteration exhibited by clients diag- nosed with severe depression. 4. Social isolation is a behavioral, not affective, alteration exhibited by clients diagnosed with severe depression. TEST-TAKING HINT: The test taker must differen- tiate affective symptoms associated with severe depression to answer this question correctly.

25. A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is a priority at this time? 1. Risk for violence: other-directed R / T poor impulse control. 2. Altered thought process R / T hallucinations. 3. Social isolation R / T manic excitement. 4. Low self-esteem R / T guilt about promiscuity.

✅ 1. Risk for violence: other-directed is defined as behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to others. Because of poor impulse control, irritability, and hyperactive psychomotor behaviors experienced during a manic episode, this client is at risk for violence directed toward others. Keeping all clients in the milieu safe is always a nursing priority. 2. Altered thought processes is defined as a state in which an individual experiences an alteration in cognitive operations and activities. Although a client at the peek of a manic episode may experience altered thought processes, of the diagnoses presented, this client problem would be less of a priority than maintaining safety. 3. Social isolation is defined as aloneness experienced by the individual and perceived as imposed by others and as a negative and threatened state. In a manic episode, the appropriate nursing diagnosis would be impaired social interaction, not social isolation, because of the presence of intrusive, not isolative, behaviors. 4. Low self-esteem is defined as a long-standing negative self-evaluation and feelings about self or self-capabilities. During a manic episode, a client is more apt to experience grandiosity than to exhibit symptoms of low self-esteem. TEST-TAKING HINT: The test taker must under- stand that during a manic episode, because of the client's experiencing poor impulse control, grandiosity, and irritability, the risk for violence toward others is increased and must be prioritized.

16. The nurse in the emergency department is assessing a client suspected of being suicidal. Number the following assessment questions, beginning with the most critical and ending with the least critical. ___ "Are you currently thinking about suicide?" ___ "Do you have a gun in your possession?" ___ "Do you have a plan to commit suicide?" ___ "Do you live alone? Do you have local friends or family?"

✅ The correct order of these assessment questions is 1, 3, 2, 4. (1) Assessment of suicidal ideations must occur before any other assessment data are gathered. If the client is not considering suicide, continuing with the suicide assessment is unnecessary. (2) Assessment of a suicide plan is next. A client's risk for suicide increases if the client has developed a specific plan. (3) Assessment of the access to the means to commit suicide is next. The ability for the client to access the means to carry out the suicide plan is an important assessment for the nurse to intervene appropriately. If a client has a loaded gun available to him or her at home, the nurse would be responsible to assess this information and initiate actions to decrease the client's access. (4) Assessment of the client's potential for rescue is next. If a client has an involved support system, even if a suicide attempt occurs, there is a potential for rescue. Without an involved support system, the client is at higher risk. TEST-TAKING HINT: When placing assessment questions in order, the test taker must take a practical approach by first determining the underlying problem being assessed (thoughts of suicide) and then ordering subsequent questions based on gathered data. The client must have a plan in place before the nurse inquires about the means necessary to implement the plan.

43. A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? 1. Calmly redirect and remove the client from the milieu. 2. Administer prescribed PRN intramuscular injection for agitation. 3. Notify the client to lower voice. 4. Obtain an order for seclusion to help decrease external stimuli.

✅ When a client experiencing mania is yelling at other peers, it is the nurse's priority to address this situation immediately. Behaviors of this type can escalate into violence toward clients and staff members. By using a calm manner, the nurse avoids generating any further hostile behaviors, and by removing the client from the milieu, the nurse protects other clients on the unit. 2.Administering a prescribed PRN intramuscular injection for agitation could be an appropriate intervention, but only after all less restrictive measures have been attempted 3.When the nurse notifies an agitated client in a manic phase of bipolar I disorder to lower voice, the nurse has lost sight of the fact that these behaviors are inherent in this client's diagnosis. The client who is yelling at another peer does not have the ability to alter behaviors in response to simple direction. 4. Obtaining an order for seclusion to help decrease external stimuli could be an appropriate intervention, but only after all less restrictive measures have been attempted. TEST-TAKING HINT: The test taker must remem- ber that all less restrictive measures must be attempted before imposing chemical or physical restraints. Understanding this would help the test taker to eliminate "2" and "4" immediately.

54. Which of the following medications may be administered before electroconvulsive therapy? Select all that apply. 1. Glycopyrrolate (Robinul). 2. Thiopental sodium (Pentothal). 3. Succinylcholine chloride (Anectine). 4. Lorazepam (Ativan). 5. Divalproex sodium (Depakote).

✅. 1. Glycopyrrolate (Robinul) is given to decrease secretions and counteract the effects of vagal stimulation induced by electroconvulsive therapy (ECT). ✅2. Thiopental sodium (Pentothal) is a short- acting anesthetic medication administered to produce loss of consciousness during ECT. ✅3. Succinylcholine chloride (Anectine) is a muscle relaxant administered to prevent severe muscle contractions during the seizure, reducing the risk for fractured or dislocated bones. 4. Because lorazepam (Ativan), a central nervous system depressant, interferes with seizure activity, this medication would be inappropri- ate to administer before ECT. 5. Because divalproex sodium (Depakote), an anticonvulsant, interferes with seizure activity, this medication would be inappropriate to administer before ECT. TEST-TAKING HINT: The test taker must recognize that any medication that inhibits seizure activity would be inappropriate to administer before ECT, which requires the client to seize.

2. Which client statement is evidence of the etiology of major depressive disorder from a genetic perspective? 1. "My maternal grandmother was diagnosed with bipolar affective disorder." 2. "My mood is a 7 out of 10, and I won't harm myself or others." 3. "I am so angry that my father left our family when I was 6." 4. "I just can't do anything right. I am worthless."

✅1. A family history of mood disorder indicates a genetic predisposition to the development of major depressive disorder. Twin, family, and adoptive studies further support a genetic link as an etiological influence in the development of mood disorders. 2. This statement by the client gives the nurse important assessment data about the client's mood, but does not address etiological influences in the development of mood disorders. 3. The development of mood disorders, from a psychoanalytic, not genetic, perspective, involves anger that is turned inward. The client in the question is experiencing anger from a paternal loss at a young age. The psychoanalytic theorist would postulate that when the loss has been incorporated into the self (ego), the anger felt for the lost father figure is turned inward toward the client's sense of self. This leads to the development of a depressive disorder. 4. The development of mood disorders, from a cognitive, not genetic, perspective involves cognitive distortions that result in negative, defeatist attitudes. Cognitive theorists believe that depression is the product of negative thinking. TEST-TAKING HINT: The test taker needs to under- stand the various theories that are associated with the development of mood disorders to answer this question correctly.

40. A client experiencing mania states, "Everything I do is great." Using a cognitive approach, which nursing response would be most appropriate? 1. "Is there a time in your life when things didn't go as planned?" 2. "Everything you do is great." 3. "What are some other things you do well?" 4. "Let's talk about the feelings you have about your childhood."

✅1. By asking, "Is there a time in your life when things didn't go as planned?" the nurse is using a cognitive approach to challenge the thought processes of the client. 2. By stating, "Everything you do is great," the nurse is using the therapeutic technique of restating. This is a general communication technique and is not considered a cognitive communication approach, which would challenge the client's thought processes. 3. By asking, "What are some other things you do well?" the nurse is using a cognitive approach by encouraging further discussion about strengths. However, the content of this communication is inappropriate because it reinforces the grandiosity being experienced by the client. 4. By stating, "Let's talk about the feelings you have about your childhood," the nurse is using an intrapersonal, not cognitive, approach by assessing the client's feelings rather than thoughts. TEST-TAKING HINT: There are two aspects of this question of which the test taker must be aware. First, the test taker must choose a statement by the nurse that is cognitive in nature and then ensure the appropriateness of the statement.

45. A client diagnosed with bipolar I disorder experienced an acute manic episode and was admitted to the in-patient psychiatric unit. The client is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply. 1. Financial and legal assistance. 2. Crisis hotline. 3. Individual psychotherapy. 4. Support groups. 5. Family education groups.

✅1. During a manic episode, clients are likely to experience impulse control problems, which may lead to excessive spending. Having access to financial and legal assistance may help the client assess the situation and initiate plans to deal with financial problems. ✅2. During a manic episode, a client may not eat or sleep and may abuse alcohol or other drugs. The client's hyperactivity may lead to ambivalence regarding his or her desire to live. Having access to a crisis hotline may help the client to de-escalate and make the difference between life and death decisions. ✅3. During a manic episode, a client most likely would have had difficulties in various aspects of interpersonal relationships, such as family, friends, and coworkers. Individuals experiencing mania may be difficult candidates for psychotherapy because of their inability to focus. When the acute phase of the illness has passed, the client may decide to access an avail- able resource to deal with interpersonal problems. Psychotherapy, in conjunction with medication maintenance treatment, and counseling may be useful in helping these individuals. ✅ 4. During a manic episode, a client would not be a willing candidate for any type of group therapy. However, when the acute phase of the illness has passed, this individual may want to access support groups to benefit therapeutically from peer support. ✅5. During a manic episode, a client may have jeopardized marriage or family function- ing. Having access to a resource that would help this client restore adaptive family functioning may improve not only relationships, but also noncompliance issues and dysfunctional behavioral pat- terns, and ultimately may reduce relapse rates. Family therapy is most effective with the combination of psychotherapeutic and pharmacotherapeutic treatment. TEST-TAKING HINT: To answer this question cor- rectly, the test taker must understand that during the manic phase of bipolar I disorder, clients engage in inappropriate behaviors that lead to future problems. It is important to provide out- patient resources to help clients avoid or minimize the consequences of their past behaviors.

52. A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client's use of grandiosity. Which is the rationale for this nurse's action? 1. Understanding the reason behind a behavior would assist the nurse to accept and relate to the client, not the behavior. 2. Change cannot occur until the client can accept responsibility for behaviors. 3. As self-esteem is increased, the client will meet needs without the use of manipulation. 4. Positive reinforcement would enhance self-esteem and promote desirable behaviors.

✅1. Grandiosity, which is defined as an exag- gerated sense of self-importance, power, or status, is used by clients diagnosed with bipolar affective disorder to help reduce feelings of insecurity by increasing feelings of power and control. When the nurse understands the origin of this behavior, the nurse can better work with, and relate to, the client. 2. It is true that change cannot occur until the client accepts responsibility for behaviors, but this is not a rationale for the nurse's action of attempting to recognize the motiva- tion behind the client's use of grandiosity. Accepting responsibility for behaviors would assist the client with the process of change, but does nothing to assist the nurse to recognize the motivation behind grandiose behavior. 3. It is true that as self-esteem is increased, the client will meet needs without the use of manipulation, but this is not a rationale for the nurse's action of attempting to recognize the motivation behind the client's use of grandiosity. Increasing self-esteem would assist the client to avoid future use of manip- ulation, but does nothing to assist the nurse to recognize the motivation behind this behavior. 4. It is true that positive reinforcement would enhance self-esteem and promote desirable behaviors, but this is not a rationale for the TEST-TAKING HINT: The test taker first must note the nursing action being addressed in the ques- tion (attempting to recognize the motivation behind the client's use of grandiosity), and then look for a specific reason the nurse implements this action (to accept and relate to the client, not the behavior).

22. Which nursing diagnosis takes priority for a client immediately after electroconvulsive therapy (ECT)? 1. Risk for injury R / T altered mental status. 2. Impaired social interaction R / T confusion. 3. Activity intolerance R / T weakness. 4. Chronic confusion R / T side effect of ECT.

✅1. Immediately after electroconvulsive therapy (ECT), risk for injury R / T altered mental status is the priority nursing diagnosis. The most common side effect of ECT is memory loss and confusion, and these place the client at risk for injury. 2. Confusion is a side effect of ECT, and this may affect the client's ability to interact socially. However, because safety is a critical concern, this diagnosis is not prioritized. 3. As consciousness is regained during the postictal period after the seizure generated by ECT, the client is often confused, fatigued, and drowsy. These symptoms may contribute to activity intolerance, but because safety is a critical concern, this diagnosis is not prioritized. 4. The most common side effects of ECT are memory loss and short-term, not chronic, confusion. TEST-TAKING HINT: To answer this question correctly, the test taker must note keywords in the question, such as "immediately after." A nursing diagnosis that would be prioritized during ECT may not be the nursing diagnosis prioritized immediately after the treatment.

32. A suicidal Jewish-American client is admitted to an in-patient psychiatric unit 2 days after the death of a parent. Which intervention must the nurse include in the care of this client? 1. Allow the client time to mourn the loss during this time of shiva. 2. To distract the client from the loss, encourage participation in unit groups. 3. Teach the client alternative coping skills to deal with grief. 4. Discuss positive aspects the client has in his or her life to build on strengths.

✅1. In the Jewish faith, the 7-day period beginning with the burial is called shiva. During this time, mourners do not work, and no activity is permitted that diverts attention from thinking about the deceased. Because this client's parent died 2 days ago, the client needs time to participate in this religious ritual. 2. By encouraging participation in group, the nurse is not addressing the client's need to focus completely on the deceased. This indicates that the nurse is unfamiliar with the religious ritual of shiva practiced by individuals of Jewish faith. 3. By teaching the client alternative coping skills to deal with grief, the nurse insinuates that the religious ritual of shiva is not a healthy coping mechanism. The nurse needs to recognize and appreciate the spiritual customs of various clients as normal behavior. 4. By focusing on discussion of the client's positive aspects, the nurse has diverted the client's attention from the deceased. The Jewish ritual of shiva requires mourners to focus completely on the deceased. The nurse needs to recognize and appreciate the spiritual customs of clients. TEST-TAKING HINT: To answer this question correctly, the test taker must be familiar with commonly occurring religious rituals that address a client's spiritual needs.

10. A client is admitted to an in-patient psychiatric unit with a diagnosis of major depres- sive disorder. Which of the following data would the nurse expect to assess? Select all that apply. 1. Loss of interest in almost all activities and anhedonia. 2. A change of more than 5% of body weight in 1 month. 3. Fluctuation between increased energy and loss of energy. 4. Psychomotor retardation or agitation. 5. Insomnia or hypersomnia.

✅1. Loss of interest in almost all activities and anhedonia, the inability to experience or even imagine any pleasant emotion, are symptoms of major depressive disorder (MDD). ✅2. Significant weight loss or gain of more than 5% of body weight in 1 month is one of the many diagnostic criteria for MDD. 3. Fluctuation between increased energy and loss of energy is an indication of mood labili- ty, a classic symptom of bipolar affective dis- order, not MDD. Manic episodes experienced by the client would rule out the diagnosis of MDD. ✅4. Psychomotor retardation or agitation, occurring nearly every day, is a diagnostic criterion for MDD. These symptoms should be observable by others and not merely subjective feelings of restlessness or lethargy. ✅5. Sleep alterations, such as insomnia or hypersomnia, that occur nearly every day are diagnostic criteria for MDD. TEST-TAKING HINT: The test taker needs to recog- nize the DSM-IV-TR criteria for the diagnosis of MDD to answer this question correctly.

35. A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship? 1. Sit with the client and offer self frequently. 2. Notify the client of group therapy schedule. 3. Introduce the client to others on the unit. 4. Help the client to identify stressors of life that precipitate life crises.

✅1. Offering self is one technique to generate the establishment of trust with a newly admitted client diagnosed with major depressive disorder (MDD). Trust is the basis for the establishment of any nurse- client relationship. 2. It is important for the nurse to promote attendance at group therapy by notifying the client of the group schedule, but this intervention does not assist the nurse to establish a nurse-client relationship. 3. A newly admitted client with a diagnosis of MDD who is isolating self is not at a point in treatment to be able to benefit from this intervention. Imposed socialization can be perceived by the client as negative because the client, as a result of depressive symptoms, is unable to be actively involved in the development of the treatment plan. 4. A newly admitted client with a diagnosis of MDD who is isolating self is not at a point in treatment to be able to benefit from this intervention. At this time, this client lacks the energy to participate actively in identifying stressors of life that precipitate life crises. TEST-TAKING HINT: The test taker must under- stand the importance of time-wise interventions. Client readiness determines appropriate and effective interventions.

28. A client has a nursing diagnosis of risk for suicide R / T a past suicide attempt. Which outcome, based on this diagnosis, would the nurse prioritize? 1. The client will remain free from injury throughout hospitalization. 2. The client will set one realistic goal related to relationships by day 3. 3. The client will verbalize one positive attribute about self by day 4. 4. The client will be easily redirected when discussion about suicide occurs by day 5.

✅1. Remaining free from injury throughout hospitalization is a priority outcome for the nursing diagnosis of risk for suicide R / T a past suicide attempt. Because this outcome addresses client safety, it is prioritized. 2. Setting one realistic goal related to relation- ships by day 3 is a positive outcome that addresses an altered social interaction problem, not a problem that deals with a risk for suicide. 3. Verbalizing one positive attribute about self by day 4 is a positive outcome that addresses a low self-esteem problem, not a problem that deals with a risk for suicide. 4. It is important to encourage clients to express suicidal ideations for the nurse to evaluate suicide risk. Redirecting the client from discussions about suicide is an inappropriate intervention; the outcome that reflects this intervention also is inappropriate. TEST-TAKING HINT: To select the correct answer, the test taker must be able to pair the nursing diagnosis with the correct outcome. There always must be a correlation between the stated problem and client expectations documented in the outcome.

9. Which client is at highest risk for the diagnosis of major depressive disorder? 1. A 24-year-old married woman. 2. A 64-year-old single woman. 3. A 30-year-old single man. 4. A 70-year-old married man.

✅1. Research indicates that depressive symptoms are highest among young, married women of low socioeconomic back- grounds. Compared with the other clients presented, this client is at highest risk for the diagnosis of major depressive disorder (MDD). 2. Research indicates that there is a higher rate of depressive disorders diagnosed in young, not older, and married, not single, women. Compared with the other clients presented, this client is at lower risk for the diagnosis of MDD. 3. Although the diagnosis of MDD is higher among single men, this client's young age places him at lower risk compared with the other clients presented. Research indicates that there is a lower rate of depressive disorders diagnosed in younger men. 4. Although the diagnosis of major depressive disorder is higher among older men, this client's marital status places him at lower risk compared with the other clients presented. Research indicates that there is a lower rate of depressive disorders diagnosed in married men. TEST-TAKING HINT: To answer this question cor- rectly, the test taker needs to understand that age and marital status affect the incidence of depression.

1. Which nursing diagnosis supports the psychoanalytic theory of development of major depressive disorder? 1. Social isolation R / T self-directed anger. 2. Low self-esteem R / T learned helplessness. 3. Risk for suicide R / T neurochemical imbalances. 4. Imbalanced nutrition less than body requirements R / T weakness.

✅1. Social isolation R/T self-directed anger supports the psychoanalytic theory in the development of major depressive disorder (MDD). Freud defines melancholia as a profoundly painful dejection and cessation of interest in the outside world, which culminates in a delusional expectation of punishment. He observed that melancholia occurs after the loss of a love object. Freud postulated that when the loss has been incorporated into the self (ego), the hostile part of the ambivalence that has been felt for the lost object is turned inward toward the ego. Another way to state this concept is that the client turns anger toward self. 2. Low self-esteem R/T learned helplessness supports a learning, not psychoanalytic, theory in the development of MDD. From a learning theory perspective, learned helpless- ness results from clients experiencing numerous failures, real or perceived. 3. Risk for suicide R/T neurochemical imbalances supports a biological, not psychoanalytic, theory in the development of MDD. From a neurochemical perspective, it has been hypothesized that depressive illness may be related to a deficiency of the neurotransmitters norepinephrine, serotonin, and dopamine at functionally important receptor sites in the brain. 4. Imbalanced nutrition less than body requirements R/T weakness supports a physiological, not psychoanalytic, theory in the development of MDD. From a physiological perspective, it has been hypothesized that deficiencies in vitamin B1 (thiamine), vitamin B6 (pyridoxine), vitamin B12, niacin, vitamin C, iron, folic acid, zinc, calcium, and potassium may produce symptoms of depression. TEST-TAKING HINT: To answer this question correctly, the test taker must be able to recognize the connection between the underlying cause (R/T) of the client's problem and the theory that is stated in the question.

6. A client expresses frustration and hostility toward the nursing staff regarding the lack of care his or her recently deceased parent received. According to Kubler-Ross, which stage of grief is this client experiencing? 1. Anger. 2. Disequilibrium. 3. Developing awareness. 4. Bargaining.

✅1. The client in the question is exhibiting anger surrounding the death of a parent. Kubler-Ross describes anger as the second stage in the normal grief response. This stage occurs when clients experience the reality of the situation. Feelings associated with this stage include sadness, guilt, shame, helplessness, and hopelessness. 2. Disequilibrium is a stage in Bowlby's, not Kubler-Ross's, model of the normal grief response. Bowlby's model consists of four stages of grief, including numbness or protest, disequilibrium, disorganization and despair, and reorganization. 3. Developing awareness is a stage in Engel's, not Kubler-Ross's, model of the normal grief response. Engel's model consists of five stages of grief, including shock/disbelief, developing awareness, restitution, resolution of loss, and recovery. 4. The client in the question is exhibiting signs of anger, not bargaining. Bargaining is the third stage of Kubler-Ross's model of the normal grief response. TEST-TAKING HINT: To answer this question correctly, the test taker must be familiar with all of the models related to the normal grief response and be able to distinguish between them.

30. The nurse is reviewing expected outcomes for a client diagnosed with bipolar I disorder. Number the outcomes presented in the order in which the nurse would address them. ___ The client exhibits no evidence of physical injury. ___ The client eats 70% of all finger foods offered. ___ The client is able to access available out-patient resources. ___ The client accepts responsibility for own behaviors.

✅1. The order in which the outcomes should be addressed is 1, 2, 4, 3. (1) The nurse would address the outcome that states, "The client exhibits no evidence of physical injury," first because this outcome deals with client physical safety. (2) Next, the nurse would address the outcome that states, "The client eats 70% of all finger foods offered," because this outcome deals with the client's physical needs. (3) The nurse would address next the outcome that states, "The client accepts responsibility for own behaviors," because this outcome is realistic only later in treatment. (4) Finally, the nurse would address the outcome that states, "The client is able to access available out-patient resources," because this outcome would be appropriate only during the discharge process. TEST-TAKING HINT: The test taker can use Maslow's hierarchy of needs to facilitate the ranking of client outcomes. In this question, "1" relates to safety, "2" relates to physical needs, and "4" relates to psychosocial needs. The time- frame in which "3" would be accomplished (discharge) determines its ranking.

37. Which intervention takes priority when working with newly admitted clients experiencing suicidal ideations? 1. Monitor the client at close, but irregular, intervals. 2. Encourage the client to participate in group therapy. 3. Enlist friends and family to assist the client to remain safe after discharge. 4. Remind the client that it takes 4 to 6 weeks for antidepressants to be fully effective.

✅Clients who experience suicidal ideations must be monitored closely to prevent suicide attempts. By monitoring at irregular intervals, the nurse would prevent the client from recognizing patterns of observation. If a client does recognize patterns of observations, the client can use the time in which he or she is not observed to plan and implement a suicide attempt. 2. It is important for a client experiencing suicidal ideations to attend group therapy to bene- fit from treatment. However, monitoring the client to prevent a suicide attempt must be prioritized. 3. The focus of nursing interventions with a newly admitted client experiencing suicidal ideations should be on maintaining safety. As the client stabilizes, the nurse can enlist friends and family to assist the client to remain safe after discharge. 4. It is important for a client experiencing suicidal ideations to understand that it takes 4 to 6 weeks for antidepressants to be fully effective. However, monitoring the client to prevent a suicide attempt must be prioritized TEST-TAKING HINT: The test taker must recognize that nursing interventions must focus on client safety when working with newly admitted clients experiencing suicidal ideations.