Mental Health PrepU
A nurse is caring for a veteran, who exhibits signs and symptoms of posttraumatic stress disorder (PTSD). Signs and symptoms of posttraumatic stress disorder include: hyperalertness and sleep disturbances. feelings of hostility and violent behavior. memory loss of a traumatic event and somatic distress. sudden behavioral changes and anorexia.
hyperalertness and sleep disturbances. Explanation: Signs and symptoms of PTSD include hyperalertness, sleep disturbances, exaggerated startle response, survivor's guilt, and memory impairment. The client may relive the traumatic event through dreams and recollections. Hostility, violent behavior, and anorexia aren't typical signs or symptoms of PTSD.
When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? cancer of any kind heart failure prescription drug intoxication impaired hearing
prescription drug intoxication Explanation: Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.
A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which conclusion should the nurse reach? The client is improving. The client is imminently suicidal. The client is overstimulated. The client's medication dosage is too high.
The client is imminently suicidal. Explanation: When a client with major depression and suicidal ideation displays a sudden elevation in mood, seems calmer, has more energy, and is more peaceful, the nurse should judge these behaviors as an indication that a suicide attempt is imminent. These symptoms may indicate relief from ambivalent thoughts about suicide and that the client has an immediate plan for killing himself.
Modafinil has been ordered for a client diagnosed with narcolepsy. The nurse understands that this medication: is a central nervous system (CNS) depressant. promotes wakefulness. is a mood stabilizer. is an antianxiety agent.
promotes wakefulness. Explanation: Although modafinil's mechanism of action isn't fully known, this drug promotes wakefulness. It's indicated for treatment of individuals with narcolepsy, obstructive sleep apnea, or shift work type sleep-wake disorder. It would increase anxiety and elevate mood. CNS depressants and antianxiety agents would worsen the symptoms of narcolepsy. Mood stabilizers aren't indicated for narcolepsy.
The client with diagnosed borderline personality disorder tells the nurse, "You are the best nurse here. I can talk to you, and you listen. You are the only one here that can help me." Which response by the nurse is most therapeutic? "Other clients have told me that too." "Mary and Sam are good nurses too." "Thank you; you are a good person." "All of the nurses here provide good care."
"All of the nurses here provide good care." Explanation: The most therapeutic response is, "All of the nurses here provide good care." This statement corrects the client's unrealistic and exaggerated perception. "Splitting," defined as the inability to integrate good and bad aspects of an individual and the self, is a hallmark behavior of a client with borderline personality disorder. The client sees himself and others as all good or all bad. Components of "splitting" include behaviors that idealize and devalue others. It is a defense that allows the client to avoid pain and feelings associated with past abuse or a current situation involving the threat of rejection or abandonment. The other statements promote the client's idealistic view and do nothing to help correct the client's distortion.
A client has been treated for major depression and is taking antidepressants. He asks the nurse, "How long do I have to take these pills?" The nurse should tell the client: "Once you are feeling better, the medication can be discontinued." "You will need to take the medication for at least 3 months." "Antidepressants are prescribed for 6 to 12 months before considering discontinuation." "The medication can be discontinued when you do not have suicidal thoughts."
"Antidepressants are prescribed for 6 to 12 months before considering discontinuation." Explanation: With major depression, antidepressants are prescribed for 6 to 12 months before the client is evaluated for discontinuation. Discontinuation of the medication prematurely may cause a relapse. An adequate duration for maintenance treatment is a minimum of 6 months; it is often longer depending on the stage of the illness and the specific client's characteristics. This regimen must be explained to clients as they often want to stop the medication when they feel better.
A client with major depression states, "Life is not worth living anymore. Nothing matters." Which response by the nurse is best? "You should not feel that way." "Things will get better, you know." "Why do you think that way?" "Are you thinking about killing yourself?"
"Are you thinking about killing yourself?" Explanation: When the client verbalizes that life is not worth living anymore, the nurse needs to ask the client directly about suicide by saying, "Are you thinking about killing yourself?" Asking directly does not provoke suicide but conveys concern, understanding, and the worth of the client. Commonly, the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan responsible care by identifying the client who is at risk for suicide. The nurse should then evaluate the seriousness of the suicidal ideation by inquiring about the intent and plan. Stating, "Things will get better," offers hope too soon without first evaluating the intent of the suicidal ideation. Asking, "Why do you think that way?" implies a lack of understanding and knowledge on the part of the nurse. Major depression usually is endogenous and biochemically based. Therefore, the client may not know why he does not want to live. Saying, "You should not feel that way," admonishes the client, decreases self-worth, and conveys a lack of understanding.
A client taking paroxetine 40 mg PO every morning tells the nurse that her mouth "feels like cotton." Which statement by the client necessitates further assessment by the nurse? "I am using sugarless gum." "I am drinking 12 glasses of water every day." "I am sucking on sugarless candy." "I am sucking on ice chips."
"I am drinking 12 glasses of water every day." Explanation: Dry mouth is a common, temporary side effect of paroxetine. The nurse needs to further assess the client's water intake when the client states she is drinking lots of water. Excessive intake of water could be harmful to the client and could lead to electrolyte imbalance. Dry mouth is caused by the medication, and drinking a lot of water will not eliminate it. Sucking on ice chips or using sugarless gum or candy is appropriate to ease the discomfort of dry mouth associated with paroxetine.
A client states that her "life has gone down the tubes" since her divorce 6 months ago. Then, after she lost her job and apartment, she took an overdose of barbiturates so she "could go to sleep and never wake up." Which statement by the nurse should be made first? "You sound hopeless about the future since your divorce." "I know you took an overdose of barbiturates. Are you thinking of suicide now?" "Helplessness is common after losing a job. Are you having trouble making decisions?" "It seems as if your self-esteem has been affected by all your losses."
"I know you took an overdose of barbiturates. Are you thinking of suicide now?" Explanation: The highest priority is assessing for suicide risk. When the client is safe, then the self-esteem, helplessness, and hopelessness issues can be addressed.
During family teaching, the daughter of a client with dementia mentions to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? "I tell her she is wrong, and then I tell her what is right." "I understand the misperceptions are part of the disease." "I tell her reality, such as, 'That noise is the wind in the trees.'" "I turn off the radio when we are in another room."
"I tell her she is wrong, and then I tell her what is right." Explanation: Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.
The nurse meets with the client and his wife to discuss depression and the client's medication. Which comment by the wife would indicate that the nurse's teaching about disease process and medications has been effective? "He is intelligent and will not need to depend on a pill much longer." "It is important to watch for physical dependency on sertraline." "His depression is almost cured." "It is important for him to take his medication so that the depression will not return or get worse."
"It is important for him to take his medication so that the depression will not return or get worse." Explanation: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Sertraline is not physically addictive.
The wife of a 67-year-old client who has been taking imipramine for 3 days asks the nurse why her husband is not better. The nurse should tell the wife: "A different antidepressant may be necessary." "Your husband may need an increase in dosage." "It takes 2 to 4 weeks before the full therapeutic effects are experienced." "It can take 6 weeks to see if the medication will help your husband."
"It takes 2 to 4 weeks before the full therapeutic effects are experienced." Explanation: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks of therapy before the full therapeutic effects are experienced. Because the client has been taking the drug for only 3 days, it is too soon to determine if the current dosage of imipramine is effective. It is also too soon to consider taking another antidepressant.
The husband of a client to be discharged from the hospital after an episode of major depression and a suicide attempt asks, "What can I do if she tries to kill herself again?" Which response is most appropriate? "Do not worry. She will be okay as long as she takes her medication." "Tell her about your concern and just take care of her." "She told me she wants to live so I do not think she will try again." "Let us talk about some behavioral clues and resources that can help."
"Let us talk about some behavioral clues and resources that can help." Explanation: The most appropriate response is to discuss the behavioral clues and resources because it provides the husband with important information that he needs to cope with his wife's condition. Family members are commonly afraid of future suicidal activity and need helpful information and resources to turn to in a crisis. Telling the husband not to worry minimizes the husband's concern and is not necessarily true. Additionally, past suicide attempts need to be considered when evaluating the client's future risk of suicide. The statement, "She told me she wants to live, so I do not think she will try again," ignores the husband's request and concerns. Additionally, there is no way for the nurse to know whether the client will attempt suicide again. The statement, "Tell her about your concern, and just take care of her," is not helpful because the husband needs information and resources to turn to should a crisis develop.
A nurse on the geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine to take "on top of his donepezil." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: "Memantine and donepezil are commonly used together to slow the progression of dementia." "Donepezil has a short half-life, and memantine has a long half-life. They work well together." "Memantine is more effective than donepezil. Your father will be tapered off the donepezil." "Maybe the donepezil alone is not improving his dementia fast enough or well enough."
"Memantine and donepezil are commonly used together to slow the progression of dementia." Explanation: Memantine and donepezil are commonly given together. Neither medicine will improve dementia, but they may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.
A nurse should intervene when a depressed client makes which statement? "Television does not interest me anymore." "I have gained a little weight." "I have trouble falling asleep." "Nobody cares about me."
"Nobody cares about me." Explanation: The client's statement "Nobody cares about me" may indicate the presence of suicidal ideation. Major themes associated with suicide are loneliness, abandonment, psychic pain, loss, helplessness, and hopelessness. The nurse should ask the client directly about suicidal thoughts and plans. Sleep disturbances are a sign that the depression still exists, but they do not indicate suicidal ideation. Thus, the statement regarding difficulty falling asleep does not require immediate intervention by the nurse. Change in appetite and decreased interest in usual activities are common symptoms of depressed mood.
A female client with acute mania brings six suitcases and three shopping bags of personal belongings on admission to the unit. When informed that some of the suitcases and bags need to be returned home with her husband because of a lack of storage space, the client begins to use profanity against the nurse. Which response by the nurse is most therapeutic? "Swearing and profanity are unacceptable here." "I will not tolerate your talking to me like that." "You are acting inappropriately." "We do not want to put you in seclusion yet."
"Swearing and profanity are unacceptable here." Explanation: By stating to the client, "Swearing and profanity is unacceptable here," the nurse is setting limits in a nonpunitive manner for behavior that is inappropriate or threatening to other clients and staff. Setting limits helps the client regain self-control, prevents alienation from others, and preserves self-esteem. It is common for the irritable manic client to misperceive the nurse's and other's statements and intentions, feel threatened, and respond in a manner that is out of character for the client when not in a manic phase. Stating that the client is acting very inappropriately or that the nurse will not tolerate the client's swearing and profanity or threatening to put the client in seclusion is threatening and punitive and thus nontherapeutic.
The client with acute mania has been admitted to the inpatient unit voluntarily. The nurse approaches the client with medication to be taken orally as prescribed by the health care provider (HCP). The client states, "I do not need that stuff." Which response by the nurse is best? "The medication will help you feel calmer." "If you do not take it orally, I will give you a shot." "You cannot refuse to take this medication." "I will get you some written information about the medication."
"The medication will help you feel calmer." Explanation: The nurse should first attempt a collaborative approach to increasing adherence to the prescribed medication regimen. Giving written medication information to a client with acute mania is poor nursing judgment because a client with acute mania cannot benefit from written information as a result of impaired ability to focus and concentrate. The client was a voluntary admission and has the right to refuse any medication. Giving the medication as an injection against the client's consent constitutes battery.
The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I am tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: "Reminding your dad that you have heard that story will help him stop." "I want you to understand your dad's level of anxiety." "You need to be more accepting of your dad's behavior." "Your dad lost his short-term memory, but he still has his long-term memory."
"Your dad lost his short-term memory, but he still has his long-term memory." Explanation: The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is being critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will.
A nurse is caring for a client diagnosed with antisocial personality disorder. This client has a history of fighting, cruelty to animals, and stealing. Which trait is the nurse likely to uncover during assessment? History of gainful employment A low tolerance for frustration Demonstrated ability to maintain close, stable relationships Frequent expression of guilt regarding antisocial behavior
A low tolerance for frustration Explanation: Clients with antisocial personality disorder exhibit emotional immaturity, a lack of impulse control, and a low tolerance for frustration. Most have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and they commonly perceive themselves as victims. They also display a lack of responsibility for the results of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships.
A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is most likely the occurrence that is disturbing to this client? A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom. There are three staff members and one health care provider (HCP) in the nurse's station working on charting. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. There is only one other client in the dayroom; the rest are in a group session in another room.
A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. Explanation: The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.
A 72-year-old female client is brought by ambulance to the hospital's psychiatric unit from a nursing home where she has been a client for 3 months. Transfer data indicate that she has become increasingly confused and disoriented. In which way should the hospital admission process be modified for the client? Allow her sufficient extra time in which to gain an understanding of what is happening to her. Give her a tour of the unit to acquaint her with the new environment in which she will live. Medicate her to ensure her calm cooperation during the admission procedure. Leave her alone to promote recovery of her faculties and composure.
Allow her sufficient extra time in which to gain an understanding of what is happening to her. Explanation: When admitting an elderly client, especially one who is confused and disoriented, it is best to give the client extra time in which to gain an understanding of what is happening to her. This will help her to get her bearings and adjust to a new environment. Leaving the client alone will not help her confusion and disorientation and will increase her fear and anxiety. Medication would not be appropriate until the cause of the client's confusion and disorientation is determined. Overmedicating elderly clients is sometimes a cause of their confusion. A tour of the unit will not be helpful for the client who is confused and disoriented.
A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication? Urinate as soon as the urge is felt. Eat a high-fiber diet. Wear sunglasses outdoors. Avoid alcohol.
Avoid alcohol. Explanation: Alcohol potentiates the central nervous system depression that can occur with imipramine, leading to increased sedation, confusion, and disorientation and consequently placing the client at risk for injury. Therefore, instructing the client and spouse about avoiding alcohol is most important. It is not necessary to eat a high-fiber diet while taking imipramine. Imipramine does not cause photosensitivity or changes in urinary patterns.
A client was found unconscious on the floor of his bathroom with self-inflicted wrist lacerations. An ambulance was called and the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Which nursing intervention is most appropriate? Observe for extrapyramidal symptoms. Begin a therapeutic relationship. Explore precipitating factors for the suicide attempt. Continue suicide precautions.
Continue suicide precautions. Explanation: As antidepressants begin to take effect and the client feels better, he may have the energy to initiate and complete another suicide attempt. As the client's energy level increases, the nurse must continue to be vigilant to the risk of suicide. Extrapyramidal symptoms may occur with antipsychotics; they are not adverse effects of antidepressants. A therapeutic relationship should be initiated upon admission to the psychiatric unit, after suicide precautions have been instituted. It is through this relationship that the client develops feelings of self-worth and trust. Although the factors that precipitated the client's suicide attempt should be explored, this nursing intervention is not a priority at this time.
Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills? Determining if the client was trying to harm himself Determining if the client has a support system Determining if the client's physical condition is life-threatening Determining if the client has a history of suicide attempts
Determining if the client's physical condition is life-threatening Explanation: If the client's physical condition is life-threatening, the priority is to treat the medical condition. Any compromise to the client's airway, breathing, or circulation must be addressed immediately. It's also imperative to determine the time of ingestion because this may determine treatment. The psychiatric evaluation, which includes intent to harm oneself, adequate support system, and history, can be performed after the client is medically stable.
A client diagnosed with major depression has started taking amitriptyline hydrochloride, a tricyclic antidepressant. What is a common adverse effect of this drug? Weight loss Muscle spasms Hypertension Dry mouth
Dry mouth Explanation: Tricyclic antidepressants can have anticholinergic adverse effects, with dry mouth being the most common. Hypotension would be expected, rather than hypertension. Weight gain — not loss — is typical when taking this medication. Muscle spasms aren't an adverse effect of tricyclic antidepressants.
During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I cannot get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. Promote relaxation before bedtime with a warm bath or relaxing music. Ask the client's health care provider (HCP) for a strong sleep medicine. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.
Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. Promote relaxation before bedtime with a warm bath or relaxing music. Explanation: A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.
A client with major depression is frequently irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach? Joyfulness Firmness Humor Aloofness
Firmness Explanation: By taking a firm approach, the nurse sets limits and establishes boundaries for the client's behavior, which helps ensure his safety and gives him a sense of control. A joyful or humorous approach may imply that the nurse isn't taking the client's concerns seriously. An aloof approach doesn't encourage communication or enable the client to initiate interpersonal contact.
During an interaction with a nurse, a client with bipolar disorder states that she doesn't have anything to contribute to the art therapy group. On exploration of the client's concerns, the nurse recognizes the client's pattern of withdrawal and nonparticipation in situations requiring her to communicate with others. Which nursing diagnosis is appropriate for this client? Defensive coping Anxiety Impaired social interaction Chronic low self-esteem
Impaired social interaction Explanation: The data obtained by the nurse support the nursing diagnosis of Impaired social interaction. Some defining characteristics of this diagnosis include having limited communication with others, verbalizing negative feelings, and feeling insecure around other people. The client may also have Anxiety, Defensive coping, and Chronic low self-esteem; however, the client exhibits the defining characteristics of Impaired social interaction.
A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which approach by the nurse is most therapeutic? Sit outside the client's room. Question the client until he responds. Initiate contact with the client frequently. Wait for the client to begin the conversation.
Initiate contact with the client frequently. Explanation: The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client's self-esteem. The nurse's action conveys acceptance of the client as a worthwhile person and provides some structure to the seemingly monotonous day. Waiting for the client to begin the conversation with the nurse is not helpful because the depressed client resists interaction and involvement with others. Sitting outside of the client's room is not productive and not necessary in this situation. If the client were actively suicidal, then a one-on-one client-to-staff assignment would be necessary. Questioning the client until he responds would overwhelm him because he could not meet the nurse's expectations to interact.
The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care? Provide for a schedule of activities outside the home. Involve the client in usual at-home activities. Discourage visitors while the client is at home. Encourage the client to sleep as much as possible.
Involve the client in usual at-home activities. Explanation: It is best to involve the client in usual at-home activities as much as the client can tolerate them. Discouraging visitors may not be in the client's best interest because visits with supportive significant others will help reinforce supportive relationships, which are important to the client's self-worth and self-esteem. Providing for a schedule of activities outside the home may be overwhelming for the client initially. Involving the client in planning for outside activities would be appropriate. Encouraging the client to sleep as much as possible is nontherapeutic and promotes withdrawal from others.
A physician orders lithium carbonate for a client who's in the manic phase of bipolar disorder. During lithium therapy, the nurse should watch for which adverse reactions? Constipation, lethargy, and ataxia Nausea, diarrhea, tremor, and lethargy Weakness, tremor, and urine retention Anxiety, restlessness, and sleep disturbance
Nausea, diarrhea, tremor, and lethargy Explanation: The most common adverse effects of lithium are nausea, diarrhea, tremor, and lethargy. Lithium doesn't cause weakness, tremor, urine retention, anxiety, restlessness, sleep disturbance, constipation, or ataxia.
A client with suicidal thoughts is admitted to an adult inpatient behavioral health unit. What should the nurse do first? Question the client further about his suicidal thoughts and plans. Initiate suicide precautions with face-to-face observation of the client at all times. Confine the client to his room and post a staff member at the door to observe his actions. Place the client on suicide watch and have a family member remain with the client.
Question the client further about his suicidal thoughts and plans. Explanation: The level of lethality of a client's suicidal thoughts depends on the presence or absence of a plan. If the client has a plan, the nurse must know what it is and whether or not the client has access to the means to complete suicide. The initiation of suicide precautions is necessary whenever a client threatens suicide, but first it is important to discover more information about what the client is thinking and planning. Unless the client has at his or her disposal the means to harm himself or herself or is constantly trying to harm himself or herself with objects on the unit, placing the client on a suicide watch or confining the client to his or her room is an overreaction to the client's disclosure of suicidal ideation.
The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine, 10 mg twice a day. The healthcare provider prescribes a selective serotonin reuptake inhibitor (SSRI), paroxetine 20 mg to be given every morning. What action should the nurse take? Give the medication as prescribed. Question the healthcare provider about the order. Ask the healthcare provider to prescribe benztropine for adverse effects. Question the dosage prescribed.
Question the healthcare provider about the order. Explanation: The nurse should question the healthcare provider about the prescription because the client who has been taking an MAOI such as phenelzine must wait 14 days after stopping the MAOI before starting an SSRI such as paroxetine. Serotonin syndrome, a potentially lethal consequence, can occur when combining an MAOI and an SSRI. Serotonin syndrome is characterized by hyperreflexia, hyperthermia, myoclonus, and other symptoms similar to neuroleptic malignant syndrome. Giving the medication as prescribed can result in serious adverse consequences, as described previously. The dosage is accurate. Benztropine is not given with an SSRI; it is an antiparkinsonian agent usually prescribed for the adverse effects of antipsychotic medication.
A client with depression is exhibiting a brighter affect, ability to attend to hygiene and grooming tasks, and is beginning participation in group activities. The nurse asks the client to identify three of her strengths. After much hesitation and thinking, the client can state she is usually a nice person, a good cook, and a hard worker. What should the nurse do next? Volunteer the client to lead the cooking group later in the day. Ask the client to identify an additional three strengths. Reinforce the client for identifying and sharing her strengths. Educate the client about the importance of medication.
Reinforce the client for identifying and sharing her strengths. Explanation: After the client identifies and shares her strengths, the nurse reinforces the client for her ability to evaluate herself in a positive manner. Doing so promotes self-esteem and offers hope for improvement. Asking the client to identify three additional strengths or volunteering the client to lead the cooking group could be too overwhelming for the client at this time and may increase her anxiety and feelings of worthlessness. Although educating the client about the importance of medication is important, doing so at another time would be more appropriate.
After telling a nurse to "pray for me," a client gives away personal possessions and shows a sudden calmness. The nurse recognizes that this behavior may signal which condition? Suicidal ideation Severe anxiety Major depression Panic attack
Suicidal ideation Explanation: Verbal clues to suicidal ideation include such statements as "Pray for me" and "I won't be here when you get back." Nonverbal clues include giving away personal possessions, a sudden calmness, and risk-taking behaviors. The nurse would recognize the combination of these signs as indicating suicidal ideation—not depression, panic, or anxiety. Clients with major depression generally do not exhibit suicidal behavior until their outlook on their problems begins to improve (an improvement in behavior should raise suspicion, especially if accompanied by sudden calmness).
The nurse is caring for a client with acute mania who is euphoric and flirtatious. The nurse overhears the client describing a sexual exploit with a group of clients seated at a table . What should the nurse do next? Inform the client that if he continues to talk about sex no one will want to be around him. Speak to the client later in private while saying nothing at this time. Continue walking down the hall, ignoring the conversation. Tell the client others may not want to hear about sex, and invite him to play a game of ping-pong.
Tell the client others may not want to hear about sex, and invite him to play a game of ping-pong. Explanation: Telling the client that others may not want to hear about sex and inviting him to play a game of ping-pong with the nurse informs the client that even though his behavior is unacceptable, the nurse considers him worthy of help. The client's thoughts and actions are out of control, and directing him to an activity with the nurse is an appropriate way of regaining control. The nurse is responsible for providing safety and security to this client and others on the unit. Continuing to walk down the hall while ignoring the conversation does nothing to meet the needs of this or other clients. Doing so also diminishes trust in the nurse. Speaking to the client later in private while saying nothing at the time allows the client to continue his provocative behavior instead of focusing his energy toward productive activity. Informing the client that if he continues to talk about sex, no one will want to be around him is not helpful because his behavior is a symptom of his illness and the statement diminishes his self-worth.
A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, "She has been in bed for a week and is not eating or showering. She told me that she did not want to kill herself, but it is not like her to do nothing for herself. She will not even talk to me when I visit her." The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason? The behaviors may reflect passive suicidal thoughts. Seeing the grandson and grandmother together will be helpful. Refusing to talk to the grandson alone indicates a major problem. The behaviors reflect altered role performance.
The behaviors may reflect passive suicidal thoughts. Explanation: Passive suicidal thoughts, such as a wish to die or giving up on self-care, can be as much of a risk as active suicidal ideation (the idea of killing one's self directly), especially for older clients because they commonly lack the means, energy, and motivation for an active suicide attempt. Seeing the grandson and grandmother together may help later. Not talking to the grandson and experiencing altered role performance may be real issues, but these are not as critical as the risk of indirect (passive) suicide.
The health care provider (HCP) prescribes a serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At what time should the nurse plan to have the blood specimen obtained? before bedtime during the afternoon before breakfast after lunch
before breakfast Explanation: Because lithium reaches peak blood levels in 1 to 3 hours, blood specimens for serum lithium concentration determinations are usually drawn before the first dose of lithium in the morning (which is usually 8 to 12 hours after the previous dose) or before breakfast. Stat lithium levels can be drawn at any time, usually when toxicity is suspected.
The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client's plan of care? watching television leading a group activity cleaning the dayroom tables reading the newspaper
cleaning the dayroom tables Explanation: The client with mania is very active and needs to have this energy channeled in a constructive task such as cleaning or tidying the dayroom. Because the client is distracted easily and can concentrate only for short periods, the successful completion of a helpful task would give the nurse the opportunity to thank the client for the help, thereby enhancing the client's self-esteem. Leading a group activity is too stimulating for the client. Participating in this type of activity also may cause the client to be disruptive. Watching television or reading the newspaper would be inappropriate for the client who cannot sit for a period of time.
In a predischarge program to educate clients with bipolar disorder and their family members, the nurse emphasizes which symptom is the most significant indicator for the onset of relapse? self-concern about increase in energy leaving a good job to start a new business decreased need for sleep and racing thoughts a sense of pleasure and motivation for new endeavors
decreased need for sleep and racing thoughts Explanation: Decreased need for sleep and racing thoughts are the most prominent hallmarks of mania. Feelings of pleasure, motivation, and increased energy, within reason, are desired experiences. Also leaving a job to start a new business is not, in itself, a sign of impending illness.
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which change in her husband's behavior may confirm her fears? disturbance in his sleep patterns problem-focused coping style increase in social interactions increased decisiveness
disturbance in his sleep patterns Explanation: Depression can be a mixture of affective responses (feelings of worthlessness, hopelessness, sadness), behavioral responses (appetite changes, withdrawal, sleep disturbances, lethargy), and cognitive responses (decreased ability to concentrate, indecisiveness, suicidal ideation). Increased decisiveness, problem-solving ability, and increased social interactions are reflective of adaptive coping.
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which change in her husband's behavior may confirm her fears? increase in social interactions problem-focused coping style increased decisiveness disturbance in his sleep patterns
disturbance in his sleep patterns Explanation: Depression can be a mixture of affective responses (feelings of worthlessness, hopelessness, sadness), behavioral responses (appetite changes, withdrawal, sleep disturbances, lethargy), and cognitive responses (decreased ability to concentrate, indecisiveness, suicidal ideation). Increased decisiveness, problem-solving ability, and increased social interactions are reflective of adaptive coping.
Which characteristic would make the nurse suspect that a client with changes in cognition has delirium? significant impairment in social or occupational functioning over time memory impairment to the degree of being called amnesia disturbances in cognition and consciousness that fluctuate during the day failure to identify objects despite intact sensory functions
disturbances in cognition and consciousness that fluctuate during the day Explanation: In addition to developing over a period of hours or days, fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia.
When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which intervention should the nurse employ as the first step? eliminating distracting stimuli such as turning off the television using gentle touch to convey empathy rephrasing questions the client does not understand asking the client to go for a walk while talking
eliminating distracting stimuli such as turning off the television Explanation: Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.
A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding? bradycardia vertigo gastritis exhaustion
exhaustion Explanation: The client in the manic phase experiences insomnia, as evidenced by his sleeping only for about 4 hours a night for the past 5 days. The client experiencing an acute manic episode is not capable of judging the need for sleep. Therefore, the nurse should assess the amount of rest the client is receiving daily to prevent exhaustion. The development of vertigo, gastritis, or bradycardia typically does not result from acute mania.
Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by: increased sleep and greater distractibility. obsession with following rules and maintaining order. flight of ideas and inflated self-esteem. decreased self-esteem and increased physical restlessness.
flight of ideas and inflated self-esteem. Explanation: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.
A client with dementia must be temporarily hospitalized. The family wants to take proactive measures to assure the client does not experience further confusion. Which measure if suggested by the family would the nurse discourage? posting a calendar in the room bringing familiar objects from home for the room keeping lights dimmed during daylight hours providing for uninterrupted sleep
keeping lights dimmed during daylight hours Explanation: Clients with dementia are at risk for sudden decreases in their mental status when placed in unfamiliar settings. Keeping clients in a darkened room during the day simulates night and can disrupt the client's sleep wake cycle which exacerbates confusion. Providing for uninterrupted sleep helps maintain cognition. Bringing familiar objects from home makes the environment more comfortable and less strange. Clocks and calendars help keep the clients oriented to time.
A nurse notices that a depressed client who has been taking amitriptyline hydrochloride for 2 weeks has become very outgoing, cheerful, and talkative. The nurse suspects that the client: is experiencing a split personality. is responding appropriately to the antipsychotic. may be experiencing increased energy and is at increased risk for suicide. is ready to be discharged from treatment.
may be experiencing increased energy and is at increased risk for suicide. Explanation: As antidepressants take effect, an individual suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Amitriptyline is an antidepressant, not an antipsychotic. The client shouldn't be discharged until his risk of suicide has diminished. His elevated mood is a response to the antidepressant, not an indication of a split personality.
A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to: provide a stimulating mealtime environment. offer finger foods and sandwiches. provide large, attractive meals. let the client choose his favorite foods.
offer finger foods and sandwiches. Explanation: Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for large meals. Providing a stimulating mealtime environment is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Letting the client choose his favorite foods is inappropriate because this client has a short attention span and has trouble making choices.
The nurse answers a call on a telephone hotline from a man who was at the crisis center once in the past when he made a suicide threat. The client says, "Do not try to help me anymore. This is it. I have had enough and I have a gun in front of me now." Then he hangs up the telephone. Which call should the nurse make first? neighbor, to request he go to the client's home immediately client's wife at work, to suggest she hurry home client, to make an attempt to calm him police, to request their intervention
police, to request their intervention Explanation: The nurse's first responsibility when a client threatens suicide is to do whatever can be done most quickly to protect the client from himself. When the nurse is in a crisis center and the client is at home, it is best to call the police to intervene. They will be able to reach the client quickly and are experienced in handling such situations. It is appropriate to err on the side of safety rather than to assume that the client is not serious about a suicide threat. Attempting to call the client first would be a serious error in judgment because the client has a lethal means, a gun, readily available and is in immediate danger of killing himself. Asking the client's wife of neighbor to intervene is inappropriate because it may cause either to be hurt, especially since the client has a weapon.
Which food should the nurse tell the client to avoid while taking phenelzine? salami roasted chicken hamburger fresh fish
salami Explanation: Phenelzine is a monoamine oxidase inhibitor (MAOI). MAOIs block the enzyme monoamine oxidase, which is involved in the decomposition and inactivation of norepinephrine, serotonin, dopamine, and tyramine (a precursor to the previously stated neurotransmitters). Foods high in tyramine—those that are fermented, pickled, aged, or smoked—must be avoided because, when they are ingested in combination with MAOIs, a hypertensive crisis occurs. Some examples include salami, bologna, dried fish, sour cream, yogurt, aged cheese, bananas, pickled herring, caffeinated beverages, chocolate, licorice, beer, red wine, and alcohol-free beer.
Which milieu activity should the nurse recommend to a client with acute mania? Select all that apply. relaxation exercises watching television listening to soft music aerobic exercise scheduled rest periods
scheduled rest periods relaxation exercises listening to soft music aerobic exercise Explanation: Scheduled rest periods, relaxation exercises, and listening to soft music are activities that reduce environmental stimuli for the client who is hyperactive, talkative, easily distracted, irritable, and angry. Aerobic exercise is also beneficial to discharge some of the client's need to be active. Watching television is not therapeutic because it would stimulate the client with acute mania.
A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. He admits drinking excessively over the previous 48 hours. This behavior is an example of: situational crisis. depression. alcoholism. a manic episode.
situational crisis. Explanation: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.
The client with major depression and suicidal ideation has been taking bupropion 100 mg PO 3 times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which behavior? suicide attempt seizure activity increased libido visual disturbances
suicide attempt Explanation: The nurse must monitor the client for a suicide attempt at this time when the client is starting to feel better because the depressed client may now have enough energy to carry out an attempt. Bupropion inhibits dopamine reuptake; it is an activating antidepressant and could cause agitation. Although bupropion lowers the seizure threshold, especially at doses greater than 450 mg/day, and visual disturbances and increased libido are possible adverse effects, the nurse must closely monitor the client for a suicide attempt. As the client with major depression begins to feel better, the client may have enough energy to carry out an attempt.
A client with depression states, "I am still feeling nauseous after I take venlafaxine. Maybe I need something else." The nurse should tell the client to: take the medication at mealtime. cut the dose in half. take venlafaxine only in the morning. take venlafaxine before bedtime.
take the medication at mealtime. Explanation: Nausea is a common adverse effect of venlafaxine; it should be taken at mealtime to minimize gastrointestinal discomfort. Venlafaxine, unless prescribed in the extended release form, is given in divided doses throughout the day. The amount should not be taken in one dose because of the drug's 3- to 7-hour half-life in adults. The dosage should not be halved unless warranted by the client's psychological condition.
The husband of a client who was diagnosed 6 years ago with Alzheimer's disease approaches the nurse and says, "I am so excited that my wife is starting to use donepezil for her illness." The nurse should tell the husband: effectiveness in the terminal phase of the illness is scientifically proven. the adverse effects of the drug are numerous. the medication is effective mostly in the early stages of the illness. the client will attain a functional level equal to that of 6 years ago.
the medication is effective mostly in the early stages of the illness. Explanation: When compared with other similar medications, donepezil has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.
The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, "I am the Queen of England. Bow before me." The nurse interprets this statement as important to document as which area of the mental status examination? attitude toward the nurse psychomotor behavior thought content mood and affect
thought content Explanation: The client's statement, "I am the Queen of England. Bow before me," is an example of a grandiose delusion and refers to thought content of the mental status examination. Examples of psychomotor behavior to be documented would include excited, typically exaggerated and repetitive physical movements, and excessive talking and gesturing. Mood is a subjective state, and affect is an observable expression of emotion. Mood is what a client tells you she is feeling, and affect is what you see the client feeling. For example, the client may state that she feels sad or happy in reference to mood. Affect refers to the display of physical emotion, commonly described as "appropriate" or "flat." Attitude toward the nurse refers to the client's behavior in the presence of the nurse during the mental status examination (pleasant and cooperative, irritable, and guarded).
A client is admitted to the psychiatric unit with a diagnosis of unipolar disorder. When the client doesn't respond to antidepressant drugs, the physician orders electroconvulsive therapy (ECT). The mechanism of action for ECT is: similar to that of antidepressant drugs. unknown. related to increased production of chemicals in the brain. related to the client's perception of ECT as a well-deserved punishment.
unknown. Explanation: The exact mechanism of action of ECT is unknown, although various theories exist. One theory, which isn't widely accepted among medical authorities, suggests that a depressed client's underlying guilt feelings are relieved by the perception of ECT as a punishment. Another suggests that ECT increases the levels of certain chemicals in the brain, such as the neurotransmitters acetylcholine, norepinephrine, and serotonin. Although authorities agree that ECT doesn't cause permanent brain damage, they don't necessarily recognize a connection between increased chemical levels in the brain and ECT. No similarity between the action of ECT and that of antidepressant medication has been proven.
