PassPoint - Mood, Adjustment, and Dementia Disorders

A client with major depression states, "Life is not worth living anymore. Nothing matters." Which response by the nurse is best?

"Are you thinking about killing yourself?"

After a few minutes of conversation, a client who is depressed wearily asks the nurse, "Why pick me to talk to? Go talk to someone else." Which reply by the nurse is best?

"I'm interested in you and want to help you."

The spouse of a client who is experiencing acute mania and swearing and using profanity apologizes to the nurse for the client's behavior. Which reply by the nurse is most therapeutic?

"This must be difficult for you."

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

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

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

Sit with the client.

When assisting a new nurse in planning a psychoeducational group for family members about depression, the nurse would suggest omitting which topic?

drug classifications

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on how much time the client spends in bed during the day.

When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that the client:

has undergone a thorough medical evaluation.

Which nursing action is most appropriate when trying to defuse a client's impending violent behavior?

helping the client identify and express feelings of anxiety and anger

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

hold the lithium and notify the physician.

A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which therapy group would be best suited for this client?

reality orientation

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 in which area of the mental status examination?

thought content

The nurse assesses a client who is receiving tricyclic antidepressant therapy. The nurse should be alert for which finding that could suggest the client is experiencing anticholinergic effects?

urine retention and blurred vision

A client with a diagnosis of major depression and a history of several suicide attempts tells a nurse, "I have no reason to live. Nobody cares about me." Which response by the nurse is most therapeutic?

"How long have you been feeling like this?"

A client is receiving 6 mg of selegiline transdermal system every 24 hours for major depression. The nurse would determine that teaching about selegiline was effective when the client makes which statement?

"I need to avoid using the sauna at the gym."

The nurse is working with a client with depression and suicidal ideation. The nurse heard the client say, "I am disappointed because thought I'd be feeling better by now since I started medication and therapy a week ago." What would be the primary nurse therapist's most therapeutic response?

"It takes time and can be frustrating to experience the physical and emotional symptoms of depression all while you learn more about yourself and try new strategies as your medication takes effect."

A nurse is administering venlafaxine capsules to a client diagnosed with depression. What education will the nurse provide to the client about venlafaxine?

"It's best to take the medication with food at the same time each day."

A client is admitted to the psychiatric unit with a diagnosis of unipolar depression. The client has not responded to antidepressant drugs, so the health care provider prescribes electroconvulsive therapy (ECT). What education will the nurse provide about the procedure to the client and family?

"The number of ECT treatments are based on your family member's response to the therapy."

A client is taking lithium carbonate. The client asks for explanations of why regular blood tests are needed. The nurse explains that it is to detect lithium toxicity. Which statement, if made by the client, indicates to the nurse that the teaching about lithium toxicity has been effective?

"There may be too much medication in my bloodstream."

A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that they have pedophilia. What should the nurse do?

Be aware of personal opinions and views.

A client was found unconscious on the bathroom floor 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?

Continue suicide precautions.

The nurse notices that a client diagnosed with major depression and social phobia must get up and move to another area when someone sits next to them. Which action by the nurse is appropriate?

Convey awareness of the client's anxiety about being around others.

A nurse is admitting a client in the crisis center who has been raped. Which is the priority nursing intervention?

Give the client immediate support and allow for privacy.

A client who has been chronically unemployed with a history of explosive anger and depression is now experiencing significant hopelessness. What would be most appropriate for the nurse to include in the client's treatment plan? Select all that apply.

Identify personal goals. Gain insight into feelings. Assess for suicidal ideation.

A nurse working in the emergency department enters the room of a client who is agitated and swears at the nurse. The client stands up and moves toward the nurse in an aggressive fashion. What is the most appropriate action by the nurse to address this situation?

Move toward the door and leave to call the crisis response team.

A nurse is caring for a client who has been diagnosed with somatic symptom disorder. The client attributes a cough to tuberculosis. A chest X-ray and skin test are negative for tuberculosis. The client begins to complain about the sudden onset of chest pain. How should the nurse react initially?

Report the client's complaint of chest pain to a physician.

A client is taking 50 mg of lamotrigine daily for bipolar disorder. The client shows the nurse a rash on their arm. What should the nurse do?

Report the rash to the health care provider (HCP).

A client visits the mental health clinic and reports being lethargic, experiencing pain in the back, having difficulty concentrating, and feeling depressed. The nurse observes patches of hair loss on the client's scalp. Which referral should the nurse make first?

a health care provider

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

cleaning the dayroom tables

The nurse develops a teaching plan for a client about the medications prescribed for depression. Which component is most important for the nurse to include?

management of common adverse effects

A nurse working on a unit with individuals who have eating disorders is interviewing a new female client. The client has lost a significant amount of weight over the past months and complains of being "sick to my stomach" when around food. The client reports that she hasn't menstruated in 3 months. What is the priority nursing intervention?

requesting an order for a pregnancy test

A nurse is assessing a client who has just been admitted to the emergency department. Which signs suggest an overdose of an antianxiety agent?

slurred speech, dyspnea, and impaired coordination

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication?

sodium

Which laboratory value will require intervention in a client who is receiving lithium?

sodium 130 mEq/L

The nurse is teaching a client and family about phenelzine. Which food should the nurse instruct the client to avoid?

sour cream

A client who is very depressed exhibits psychomotor deficits, a flat affect, and apathy. The nurse observes that the client needs grooming and hygiene. Which nursing action is most appropriate?

stating to the client that it's time for them to take a shower

A client has been treated for major depression and is taking antidepressants. They ask the nurse, "How long do I have to take these pills?" How should the nurse respond to the client's question?

"Antidepressants are prescribed for 6 to 12 months before considering discontinuation."

A client taking mirtazapine is disheartened about a 20-lb (9 kg) weight gain over the past 3 months. The client tells the nurse, "I stopped taking my mirtazapine 15 days ago. I don't want to get depressed again, but I feel awful about my weight." Which response by the nurse is most appropriate?

"I hear how difficult this is for you and will help you approach your health care provider (HCP) about it."

After a period of unsuccessful treatment with amitriptyline, a client diagnosed with depression is switched to tranylcypromine. Which statement by the client indicates the client understands the side effects of tranylcypromine?

"I must refrain from eating aged cheese or yeast products."

At night, an elderly client with senile dementia wanders into other clients' rooms, awakening them. What is the best nursing intervention for dealing with this client's insomnia and nocturnal roaming?

Administer a low-dose antipsychotic at bedtime as ordered.

Which nursing strategy would be effective in managing a client who has Alzheimer's disease and wanders?

Involve the client in activities that promote walking.

A client with stage 1 Alzheimer's disease is diagnosed with terminal lung cancer. The client wonders about "reaching the end" asks the nurse what to do. How should the nurse respond?

"An advance directive will help to make sure that your wishes are carried out."

After the nurse teaches a client about lorazepam, which client statement(s) would indicate the need for further instruction? Select all that apply.

"I can adjust the dosage when I feel more anxious." "I can stop taking lorazepam immediately if I need to."

The family of a client diagnosed with Alzheimer disease wants to keep the client at home. They say that they have the most difficulty in managing the client's wandering. What should the nurse instruct the family to do? Select all that apply.

Have the client wear a medical alert bracelet. Install door alarms and high door locks. Install motion and sound detectors.

The nurse is instructing a client on a tyramine-free diet. Which dietary selection by the client requires further discussion?

aged cheese, Chianti wine, and garlic bread

The nurse is assessing a 38-year-old client at risk for suicide. Which are significant assessment data when determining whether a client will require hospitalization? Select all that apply.

being intoxicated with alcohol having an organized plan a description of command hallucinations

The nurse cares for the client diagnosed with delirium. The nurse should investigate which condition as most important?

prescription drug intoxication

A client with depression doesn't respond to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). The nurse knows that most people respond emotionally to the thought of an electric current passing through the brain. Therefore, when discussing ECT with the client, the nurse should:

refer to the procedure as a "treatment" instead of "shock therapy."

The nurse is conducting a group therapy session in the psychiatric unit. What action by the nurse best displays the role that milieu plays in the therapy on an inpatient unit?

structuring the environment so that stressors are used as opportunities for assessment and learning

When caring for an adolescent diagnosed with depression, the nurse should remember that depression manifests differently in adolescents than it does in adults. In an adolescent, signs and symptoms of depression are likely to include:

truancy, a change of friends, social withdrawal, and oppositional behavior.

The nurse assesses a client with depressive disorder for discharge readiness. Which behavior would lead the nurse to determine that the client is ready for discharge?

verbalization of feeling in control of self and situations

A young woman comes to the mental health clinic for their routine medication follow-up. The client has been married for 2 years and reports that they and their spouse are ready to start a family. The client has a diagnosis of bipolar disorder that has been well-managed with divalproex sodium for at least 3 years. What is the most essential counsel for the nurse to give the client?

"Check with your health care provider as divalproex carries an increased risk for birth defects."

An unlicensed assistive personnel (UAP) approaches the nurse and states, "The client doesn't know what caused them to be so depressed. They must not want to tell me because they don't trust me yet." In responding to this staff member, which statement by the nurse will help the UAP understand the client's illness?

"Endogenous depression is biochemical and isn't caused by an outside stressor or problem. The client can't tell you why he's depressed because he really doesn't know."

The client who has been taking venlafaxine 25 mg orally three times a day for the past 2 days states, "This medicine isn't doing me any good. I'm still so depressed." Which response by the nurse is most appropriate?

"It takes about 2 to 4 weeks to receive the full effects."

Though smoking is prohibited on hospital property, a client with anti-social personality disorder smokes in the client lounge and refuses to follow other unit and hospital rules. The client gets others to do the client's laundry and other personal chores and refuses to work with nurses the client doesn't like. The plan of care for this client should focus on what?

consistently enforcing unit rules and facility policy

A nurse is caring for a client in an acute manic state. What is the most effective nursing action that can be taken on behalf of this client?

reducing stimuli for the client

A client with dementia is eating off of other clients' meal trays. After the client with dementia is asked to stop, which action should be taken?

Distract the client.

A physician orders electroconvulsive therapy (ECT) for a severely depressed client who fails to respond to drug therapy. When teaching the client and family about the treatment, the nurse should include which point about ECT?

ECT will induce a seizure.

A client with a depressive disorder has been consistent with taking 12.5 mg of paroxetine extended-release daily. The nurse judges the client to be benefiting from this drug therapy when the client demonstrates which behavior(s)? Select all that apply.

completes homework assignments decreases pacing verbalizes feelings

During a night shift, a hospitalized client with depression tells a nurse that she is going to kill herself. The client is placed on constant observation. When the client asks to use the toilet, the nurse follows her into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which of the following responses by the nurse is most appropriate?

"I must stay with you until we are sure you will not hurt yourself."

A client taking tranylcypromine sulfate for depression was treated in the emergency department for a headache, vomiting, and blood pressure of 190/100 mm/Hg following dinner at a restaurant. At discharge, the nurse evaluated the client's understanding of diet instructions. For what menu choice will the nurse provide further education?

Mexican sausage soup with guacamole and chips

In assessing an adolescent client at an outpatient clinic, the nurse is able to recognize that depression in adolescents is often what?

often masked by aggressive behaviors

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

persistent GI upset

A client is a 25-year-old pregnant mother of two children under the age of 6. She is a very protective mother and will not allow her children play outdoors for fear of tick bites. She tells the nurse that she feels "worn out" from cleaning the house from top to bottom every day. She asks the nurse how she can stop worrying so much. What is the most appropriate response from the nurse?

"Tell me your concerns about the children playing in your backyard."

A 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. The client states, "I don't need that stuff." Which response by the nurse is best?

"The medication will help you feel calmer."

The family caregiver of a client with Alzheimer disease tells the nurse that the client thinks someone is stealing their things. Which response by the nurse would be most helpful?

"We asked the health care provider to evaluate the client for paranoid delusions, which are common in people with Alzheimer's disease."

A client was found wandering in a local park, unable to state who or where the client is or where the client lives. The client is brought to the emergency department, where an identification is eventually made. The client's spouse states that client was diagnosed with Alzheimer's disease 3 years earlier and has experienced increasing memory loss. The spouse reports worry about how to continue to care for the client. Which response by the nurse is most helpful?

"What aspect of caring for your spouse is causing you the greatest concern?"

A client states, "I feel so sad. I don't think I can go on anymore." Which is the most therapeutic response the nurse can offer the client?

"You feel like you can't go on anymore?"

A client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." How should the nurse respond?

"You're frightened. This is a hospital and these people are staff members. You're safe here."

The nurse is caring for a severely depressed client. Which statement by the nurse is best when talking to the client on the patient care unit?

"You're wearing a new shirt today."

The client is to undergo a series of diagnostic tests to determine if their cognitive impairment is treatable. Which state can lead to nonreversible cognitive impairment?

Alzheimer disease

The nurse cares for a client who is breathing rapidly, is pacing back and forth across the room, and has their lips tightly closed and their arms crossed tightly across their chest. What should the nurse do first?

Assist the client to a safe, calm environment.

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

Avoid alcohol.

A client with Alzheimer disease has been prescribed donepezil 5 mg at bedtime. Which instruction should the nurse give to the client's caretaker?

Avoid suddenly stopping the medication.

The child of a client with Alzheimer's disease reports feeling guilty for wishing, at times, that the parent would die. What is the nurse's best response?

Make an immediate appointment to visit the home to assess the situation.

The community psychiatric nurse conducts a weekly education group for older adult clients. The nurse suspects that one of the clients with cognitive impairment is experiencing elder abuse based on bruising, but the client mentions experiencing falls at home. What is the nurse's priority action?

Make an immediate appointment to visit the home to assess the situation.

A client in the manic phase of bipolar disorder constantly belittles other clients and is demanding special favors from the nurses. Which intervention by the nurse would be most appropriate for this client?

Set limits with specific and consistent consequences for belittling or demanding behavior.

A client is scheduled for the first electroconvulsive therapy (ECT) treatment in the morning and has been unable to sleep. In what order should the nurse perform the interventions from first to last? All options must be used.

Sit quietly with the client. Discuss specific concerns. Offer use of an audio recording with relaxing music. Encourage the use of prescribed PRN temazepam.

A 14-year-old adolescent tells the nurse about being in love with a 22-year-old neighbor and that they've had sex on several occasions. The client doesn't want the parents to know because the client is in love and is afraid the parents will be angry. What is the nurse's best course of action?

Tell the adolescent that the law requires the nurse to report the sexual contact because of the age difference.

A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which conclusion should the nurse reach?

The client is imminently suicidal.

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

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

A client with Alzheimer's disease is experiencing difficulty processing and completing complex tasks. What is a priority to include in the plan of care?

asking the client to do one step of the task at a time

A client with Alzheimer disease is asked how by the nurse how they cut their finger. "While cutting flowers in our garden," the client states. The client's spouse later tells the nurse that they do not have a flower garden. The nurse interprets the client's statement as which process?

confabulation

In a predischarge program to educate clients with bipolar disorder and their family members, the nurse emphasizes that which symptom is the most significant indicator for the onset of relapse?

decreased need for sleep and racing thoughts

A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which problem?

delusion

A client with a diagnosis of schizophrenia is experiencing paranoia and tells the nurse about hearing a voice saying, "Don't take those poisoned pills from that nurse!" Which objective assessment regarding this statement will the nurse report to the healthcare team?

disturbed perceptions

The nurse is evaluating the test results of a client undergoing testing for depression. Which results of from a dexamethasone suppression test (DST) would the nurse interpret as indicative of depression?

elevated afternoon serum cortisol

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?

firmness

A client who has paranoid personality disorder is participating in a treatment group. Which behavior should the nurse observe for as the client participates in the group?

hypervigilance

A client suffers from depression following the accidental death of a child. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the nurse learns that the client no longer wants to die. The nurse should:

inspect the client's personal belongings for potentially dangerous objects.

A 3-year-old is seen in the well child clinic. The parent is concerned that the child may be autistic. Which assessment data would indicate a concern to the nurse? Select all that apply.

lack of communication abilities withdrawing into a private world inability to develop social skills

A nurse is caring for a client who is on close observation for suicide. When accompanying this client to the bathroom, the nurse should:

observe the client.

A client chronically complains of being unappreciated and misunderstood by others, is argumentative and sullen, and always blames others for the client's failure to complete work assignments. The client expresses feelings of envy toward people the client perceives as more fortunate. The client voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?

passive-aggressive personality

The nurse answers a call on a telephone hotline from a client who was at the crisis center once in the past when they made a suicide threat. The client says, "Don't try to help me anymore. This is it. I've had enough, and I have a gun in front of me now." Then the client hangs up the telephone. Which call should the nurse make first?

police, to request their intervention

A young adult client diagnosed with bipolar disorder has been managing the disorder effectively with medication and treatment for several years. The client suddenly becomes manic. The nurse reviews the client's medication record. Which new medication may have contributed to the development of their manic state?

prednisone