Semester 3 Unit 5

While walking to the examination room with the nurse, a toddler with autism suddenly runs to the wall and starts banging the head on it. What should the nurse's initial action be 1Allowing the toddler to act out feelings 2Asking the toddler to stop this behavior 3Restraining the toddler to prevent head injury 4Telling the toddler that the behavior is unacceptable

3Restraining the toddler to prevent head injury The child with autism needs protection from self-injury. Permitting the child to act out is possible only if the acting out does not place the child in jeopardy. The child with autism has difficulty following directions, especially when out of control. The child with autism cannot separate self from behavior; a punitive approach will decrease the child's self-esteem.

A new mother is diagnosed with depression. Which antidepressant may be prescribed to this client? A. Sertraline B. Fluoxetine C. Amphetamine D. Carbamazepine

A. Sertraline Sertraline is considered safe in lactating females. Dosing immediately after breast-feeding can reduce the risk of the drug excreted in the breast milk by the next feeding time. Fluoxetine and amphetamine are not recommended for breast-feeding clients. Carbamazepine is not used to treat depression.

The HCP ordered Sertaline (zoloft) after 3 days, says the med is not working. The RN should respond a. cheer up, you have so much to be happy about b. sometimes its takes 4-6 weeks to see improvements in symptoms c. Give it 2 days and you should see improvements in your symptoms d. I'll call the HCP and get an order to change the medication

b. sometimes its takes 4-6 weeks to see improvements in symptoms

A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) does the nurse anticipate that the primary healthcare provider may prescribe? Haloperidol Fluvoxamine Imipramine Benztropine

Fluvoxamine Fluvoxamine inhibits central nervous system neuron uptake of serotonin but not of norepinephrine. Haloperidol is not an SSRI; it is an antipsychotic that blocks neurotransmission produced by dopamine at synapses. Imipramine is a tricyclic antidepressant, not an SSRI. Benztropine is an antiparkinsonian agent, not an SSRI.

The activity of gamma-aminobutyric acid (GABA) contributes to a slowing of neural activity. Which of the following drugs facilitates the action of GABA? a. Benzodiazepines b. Antihistamines c. Anticonvulsants d. Noradrenergic

a. Benzodiazepines

Which chronic medical condition is a common trigger for major depressive disorder? a. Pain b. Hypertension c. Hypothyroidism d. Crohn's disease

a. Pain

The biological approach to treating depression with electrodes surgically implanted into specific areas of the brain to stimulate the regions identified to be underactive in depression is: a. Transcranial magnetic stimulation b. Deep brain stimulation c. Vagus nerve stimulation d. Electroconvulsive therapy

b. Deep brain stimulation

Which medication should the nurse be prepared to educate patients on when they are prescribed a selective serotonin reuptake inhibitor (SSRI) for panic attacks? a. Alprazolam (Xanax) b. Fluoxetine (Prozac) c. Clonazepam (Klonopin) d. Venlafaxine (Effexor)

b. Fluoxetine (Prozac)

When working with a client who is depressed, what should the nurse do initially? A. Accept what the client says. B. Attempt to keep the client occupied. C. Keep the client's surroundings cheery. D. Try to prevent the client from talking too much

A. Accept what the client says. Because clients cannot be argued out of their feelings, it is best to initially accept what they say; it also encourages communication. Attempting to keep the client occupied delays discussing the client's feelings, and the client's low energy level may prevent involvement in activities. Keeping the client's surroundings cheery has little effect on the depressed client; it can increase depression. The depressed client does very little talking and needs to be encouraged to communicate.

A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? A. Depression B. Dependency C. Marital stress D. Identity confusion

A. Depression Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.

While playing with a toy car, a toddler accidentally hits the wall and falls down. The toddler then gets angry at the wall for making him fall. Which characteristic of preoperational thought does this behavior indicate? a. Animism b. Centration c. Egocentrism d. Irreversibility

Animism is an act of attributing lifelike qualities to inanimate objects. When a toddler scolds the wall for making him or her fall, it indicates animism. Centration is focusing on one aspect rather than considering all possible alternatives. Egocentrism is the inability to envision situations from perspectives other than one's own. Irreversibility is the inability of toddlers to reverse actions that are physically initiated.

Alprazolam is prescribed for a client with the diagnosis of panic disorder. The client refuses to take the medication because of fears of addiction. What should the nurse do initially? A. Provide the client information about alprazolam. B. Assess the client's feelings about alprazolam further. C. Ask the practitioner about changing the client's medication. D. Have the practitioner speak with the client about the safety of this medication.

B. Assess the client's feelings about alprazolam further. Before deciding how to ease the client's fears of addiction, the nurse must explore the full extent of the client's knowledge and feelings about taking this medication. Information may or may not be helpful; the client's feelings are what must be addressed. Although the nurse may eventually ask the practitioner to consider changing the medication or to speak with the client about its safety, neither is the priority at this time.

Which sedative-hypnotics are used to treat insomnia effects associated with a panic disorder? Select all that apply. A. Phenelzine B. Paroxetine C. Alprazolam D. Imipramine E. Clonazepam

C. Alprazolam E. Clonazepam Alprazolam and clonazepam are examples of benzodiazepines, a class of sedative-hypnotics used to treat clients with insomnia effects associated with panic disorders. Phenelzine is a monoamine oxidase inhibitor used to treat panic disorders and promote sleep. Paroxetine is a selective serotonin reuptake inhibitor used to treat panic disorders and promote sleep. Imipramine is a tricyclic antidepressant used to treat panic disorders and promote sleep.

An older client who lost a spouse 20 years ago comes to the community health center with a vague list of complaints and a brief life history. The couple's only child died at birth. The client lives alone and is able to perform all the activities of daily living. The client has had an active social life in the past but has outlived many friends and family members. What is an important question for the nurse to ask when taking this client's health history? A. "Are you all alone?" B. "How did your son die?" C. "Do you still miss your spouse?" D. "How do you feel about your life now?"

D. "How do you feel about your life now?" The answer to "How do you feel about your life now?" will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Are you all alone?" is probing and provides little information for the nurse to use in planning care. "How did your son die?" and "Do you still miss your spouse?" are both probing, disregard the client's present situation, and provide little information for the nurse to use in planning care.

What score on the EPDS would promote the to suspect possible depression and need further assessment A. 2 B. 5 C. 10 D. 15

D. 15 A maximum score 30 Scores of 12 or higher → possible depression and need further assessment.

Two months ago, Natasha's husband died suddenly and she has been overwhelmed with grief. When Natasha is subsequently diagnosed with major depressive disorder, her daughter, Nadia, makes which true statement? a. "Depression often begins after a major loss. Losing dad was a major loss." b. "Bereavement and depression are the same problem." c. "Mourning is pathological and not normal behavior." d. "Antidepressant medications will not help this type of depression."

a. "Depression often begins after a major loss. Losing dad was a major loss."

Which assessment question asked by the nurse demonstrates an understanding of comorbid mental health conditions associated with major depressive disorder? Select all that apply. a. "Do rules apply to you?" b. "What do you do to manage anxiety?" c. "Do you have a history of disordered eating?" d. "Do you think that you drink too much?" e. "Have you ever been arrested for committing a crime?"

b. "What do you do to manage anxiety?" c. "Do you have a history of disordered eating?" d. "Do you think that you drink too much?"

A primary healthcare provider prescribes an antidepressant for a hospitalized client who has been severely depressed. Eight days later the nurse notes that the client is neatly dressed and well groomed. The client smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the client's statement? A. Complimenting the client's appearance B. Starting preparations for the client's discharge C. Arranging for constant supervision of the client D. Adding privileges to the client's plan of care as a reward

C. Arranging for constant supervision of the client A change in behavior that seems positive may actually indicate that the client has worked out a plan for suicide; the potential for suicide increases when physical energy returns. Increased supervision is needed. Complimenting the client's appearance may increase the client's feelings of inadequacy, because it implies that the client did not look good before. It is inappropriate to consider discharge simply because of a change in behavior. Many factors should be considered in the decision to discharge a client. The addition of privileges is not indicated at this time.

What should the nurse keep in mind about rituals when planning care for a client who uses ritualistic behavior? They help the client control anxiety. They are under the client's conscious control. They are used by the client primarily for secondary gains. They help the client focus on the inability to deal with reality.

They help the client control anxiety. The rituals used by a client with obsessive-compulsive disorder help control the anxiety level by maintaining a set pattern of action. The client cannot consciously control the ritual. Rituals are used primarily to handle feelings of anxiety and generally are seen by the client as illogical; they provide few secondary gains. Rituals are a means of diverting attention from feelings of anxiety.

A client's hands are raw and bloody from a ritual involving frequent hand washing. Which defense mechanism does the nurse identify? Undoing Projection Introjection Suppression

Undoing is an act that partially negates a previous one; the client is using this primitive defense mechanism to reduce anxiety. Clients who wash their hands compulsively may be having thoughts that they consider "dirty." Projection is the attribution of one's thoughts or impulses to another. Introjection is treating something outside the self as if it is actually inside the self. Suppression is a process that is often listed as a defense mechanism, but it is actually a conscious, intentional exclusion of material from one's awareness.

Which patient has an increased risk for the development of anxiety and will require frequent assessment by the nurse? Select all that apply. a. Exacerbation of asthma signs and symptoms b. History of peanut and strawberry allergies c. History of chronic obstructive pulmonary disease d. Current treatment for unstable angina pectoris e. History of a traumatic brain injury

a. Exacerbation of asthma signs and symptoms c. History of chronic obstructive pulmonary disease d. Current treatment for unstable angina pectoris e. History of a traumatic brain injury

Tammy, a 28-year-old with major depressive disorder and bulimia nervosa, is ready for discharge from the county hospital after 2 weeks of inpatient therapy. Tammy is taking citalopram (Celexa) and reports that it has made her feel more hopeful. With a secondary diagnosis of bulimia nervosa, what is an alternative antidepressant to consider? a. Fluoxetine (Prozac) b. Isocarboxazid (Marplan) c. Amitriptyline d. Duloxetine (Cymbalta)

a. Fluoxetine (Prozac)

A client consumes alcohol during pregnancy. Which condition does the nurse anticipate to be seen in the newborn? a. Stillbirth b. Heart defects c. Growth delay d. Multiple defects

a. Stillbirth

(perry) A women in childbearing years should have at least how much folic acid daily?

at least 0.4 mg (400 mcg) of folic acid daily in addition to consuming a diet rich in folate-containing foods

Which statement made by a new mother should be explored further by the nurse? a. "I have three children, that's enough." b. "I think the baby cries just to make me angry." c. "I wish my husband could help more with the baby." d. "Babies are a blessing, but they are a lot of work."

b. "I think the baby cries just to make me angry."

Which statement(s) made by the nurse demonstrates an understanding of the effective use of relaxation therapy for anxiety management? Select all that apply. a. "Relaxation therapy's main goal is to prevent exhaustion by removing muscle tension." b. "Muscle relaxation promotes the relaxation response." c. "Show me how you learned to deep breathe in yesterday's therapy session." d. "You've said that going to group makes you nervous so let's start relaxing now." e. "I've given you written descriptions of the various relaxation exercises for you to review."

b. "Muscle relaxation promotes the relaxation response." c. "Show me how you learned to deep breathe in yesterday's therapy session." d. "You've said that going to group makes you nervous so let's start relaxing now." e. "I've given you written descriptions of the various relaxation exercises for you to review."

Which interventions does the nurse implement to empower a family who has a child with Down syndrome? Select all that apply. a. Ask the family to engage in spiritual activities. b. Help the family recognize the possible stressors. c. Encourage the use of problem-solving strategies. d. Encourage more out-of-home activities for the parents. e. Refer the family to support groups and Internet resources.

b. Help the family recognize the possible stressors. c. Encourage the use of problem-solving strategies. e. Refer the family to support groups and Internet resources. The nurse understands that the family experiences multiple stressors and helps the family recognize those stressors. The nurse encourages the family to use effective problem-solving skills that convey support and care and have a calming influence on the child. The nurse also identifies proper support groups for the family to relieve stress. The use of Internet resources will help the family understand more about the child's disorder. Asking the family to engage in spiritual activities is not appropriate, because spirituality is a personal lifestyle choice. The nurse encourages the parents to spend more time at home to provide care for the child, as opposed to engaging in more out-of-home activities.

Samantha is a new patient to the mental health clinic and is seeking assistance for what she describes as "severe anxiety." In addition to daily self-medicating with alcohol, Samantha describes long-term use of herbal kava. The nurse knows that kava is associated with inhibiting P450 and orders which of the following tests? a. Electrocardiogram b. Liver enzymes c. Glomerular filtration rate d. Complete blood count

b. Liver enzymes

(pharm book ) The nurse is teaching a patient about treatment with an SSRI antidepressant. Which teaching considerations are appropriate? (Select all that apply.) a. The patient should be told which foods contain tyramine and instructed to avoid these foods. b. The patient should be instructed to use caution when standing up from a sitting position. c. The patient should not take any products that contain the herbal product St. John's wort. d. This medication should not be stopped abruptly. e. Drug levels may become toxic if dehydration occurs. f. The patient should be told to check with the prescriber before taking any over-the-counter medications.

b. The patient should be instructed to use caution when standing up from a sitting position. c. The patient should not take any products that contain the herbal product St. John's wort. d. This medication should not be stopped abruptly. f. The patient should be told to check with the prescriber before taking any over-the-counter medications.

The nurse is providing care for a patient demonstrating behaviors associated with moderate levels of anxiety. What question should the nurse ask initially when attempting to help the patient deescalate their anxiety? a. "Do you know what will help you manage your anxiety?" b. "Do you need help to manage your anxiety?" c. "Can you identify what was happening when your anxiety began to increase?" d. "Are you feeling anxious right now?"

c. "Can you identify what was happening when your anxiety began to increase?"

Isabel is a straight-A student, yet she suffers from severe test anxiety and seeks medical attention. The nurse interviews Isabel and develops a plan of care. The nurse recognizes effective teaching about mild anxiety when Isabel states: a. "I would like to try a benzodiazepine for my anxiety." b. "If I study harder, my anxiety level will go down." c. "Mild anxiety is okay because it helps me to focus." d. "I have fear that I will fail at college.

c. "Mild anxiety is okay because it helps me to focus."

A homebound patient diagnosed with agoraphobia has been receiving therapy in the home. The nurse evaluates patient teaching is effective when the patient states: a. "I may never leave the house again." b. "Having groceries delivered is very convenient." c. "My risk for agoraphobia is increased by my family history." d. "I will go out again, someday, just not today."

c. "My risk for agoraphobia is increased by my family history."

(pharm book ) After a patient has been treated for depression for 4 weeks, the nurse calls the patient to schedule a follow-up visit. What concern will the nurse assess for during the conversation with the patient? a. Weakness b. Hallucinations c. Suicidal ideation d. Difficulty with urination

c. Suicidal ideation

When a nurse uses therapeutic communication with a withdrawn patient who has major depression, an effective method of managing the silence is to: a. Meditate in the quiet environment b. Ask simple questions even if the patient will not answer c. Use the technique of making observations d. Simply sit quietly and leave when the patient falls asleep

c. Use the technique of making observations

Cabot has multiple symptoms of depression including mood reactivity, social phobia, anxiety, and overeating. With a history of mild hypertension, which classification of antidepressants dispensed as a transdermal patch would be a safe medication? a. Tricyclic antidepressants b. Selective serotonin reuptake inhibitors c. Serotonin and norepinephrine reuptake inhibitors d. Monoamine oxidase inhibitor

d. Monoamine oxidase inhibitor

What characteristics are commonly associated with adolescent depression? Select all that apply. A. Exercising daily B. Having suicidal ideation C. Exhibiting tearfulness D. Having poor muscle tone E. Avoiding previously enjoyed activities and relationships

B. Having suicidal ideation C. Exhibiting tearfulness E. Avoiding previously enjoyed activities and relationships Having suicidal ideation, exhibiting tearfulness, and avoiding previously enjoyed activities and relationships are characteristic features of depression. Having poor muscle tone and performing physical exercise routine are uncommon in depressed adolescents.

During a community health survey, the nurse is conducting a survey about the language development in preschoolers. What behavior is the nurse able to document in preschoolers? Select all that apply. A. Preschoolers start to understand riddles and jokes. B. Preschoolers want to know the reason behind an event. C. Preschoolers have a vocabulary of 8,000 to 14,000 words. D. Preschoolers know that words may have arbitrary meanings. E. Preschoolers cannot distinguish between phonetically similar words

B. Preschoolers want to know the reason behind an event. C. Preschoolers have a vocabulary of 8,000 to 14,000 words. E. Preschoolers cannot distinguish between phonetically similar words Preschoolers start to question "Why?" and "How come?" Their vocabulary increases rapidly and they can define their feelings by using 8,000 to 14,000 words. School-aged children are able to understand riddles and jokes. This is not seen in preschool children. School-aged children clearly understand that words have arbitrary meanings. This is not seen in preschoolers. Preschoolers get confused between phonetically similar sounds. They are not able to understand the difference between die and dye or wood or would. Therefore, the nurse will not document this behavior with preschoolers.

Which response by a 15-year-old demonstrates a common symptom observed in patients diagnosed with major depressive disorder? a. "I'm so restless. I can't seem to sit still." b. "I spend most of my time studying. I have to get into a good college." c. "I'm not trying to diet, but I've lost about 5 pounds in the past 5 months." d. "I go to sleep around 11 p.m. but I'm always up by 3 a.m. and can't go back to sleep."

d. "I go to sleep around 11 p.m. but I'm always up by 3 a.m. and can't go back to sleep.

On the third postpartum day, the nurse enters the room of a client who had an unexpected cesarean birth and finds her crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" What should the nurse consider when responding? A. The client's feelings will pass after she has bonded with her infant. B. The client is probably suffering from postpartum depression and needs special care. C. A cesarean birth may be a traumatic experience, but most women know that it is a possible outcome. D. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this.

D. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this. The client's response is appropriate to the situation, reflecting disappointment in not achieving her goal; in addition, this is the time when "postpartum blues" occurs. The client's feelings may or may not pass after she has bonded with her infant; there is no indication that the feeling will pass or that bonding is involved. The client's statement is not indicative of depression. With rising cesarean rates across the United States, most women know that a cesarean birth is a real possibility. However, knowing this does not negate the disappointment a client may feel over not reaching her goal

Which medications are used to treat generalized anxiety disorder (GAD)? Select all that apply. A. Duloxetine B.Venlafaxine C. Clonazepam D. Escitalopram E. Clomipramine

A. Duloxetine B.Venlafaxine D. Escitalopram Duloxetine, venlafaxine, and escitalopram are antidepressants approved for the treatment of generalized anxiety disorder (GAD). Clonazepam and clomipramine are used to treat panic disorders.

During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. A. Lethargy B. Ambivalence C. Emotional lability D. Increased appetite E. Long periods of sleep

A. Lethargy B. Ambivalence C. Emotional lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.

Which symptoms of depression, often overlooked in the older adult client, should the nurse include in the assessment process? Select all that apply. A. Anxiety B. Insomnia C. Weight loss D. Weight gain E. General fatigue

B. Insomnia E. General fatigue Insomnia and general fatigue are symptoms of depression that are often overlooked for the older adult client. Anxiety, weight loss and weight gain are all symptoms of depression; however, these symptoms are not often overlooked for the older adult client.

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to? A. Modifying the environment B. Limiting the client's choices of diet and clothing C. Encouraging fluid intake D. Discouraging social interaction to avoid the client's distraction from outside environment

D. Discouraging social interaction to avoid the client's distraction from outside environment The nursing student's act of discouraging interactions due to fear of the client's distraction may result in a lack of improvement. Social interactions should be encouraged instead. Modifying the environment may help to provide better healthcare. The nurse should limit the client's choices of food and clothing to relieve any decision-making stress. The nurse should also encourage fluid intake.

During a therapy group session, after several members relate traumatic incidents that happened during the week, a client says with a smile, "Things haven't gone well in my life this week either." It is most appropriate for the nurse to: A. Ask the client to share what has happened this week. B. Make a note of the incongruity of the client's message but remain silent. C. Comment, "This seems to have been a bad week for several of our members." D. Say to the client, "You say things have been bad this week, but you're smiling."

D. Say to the client, "You say things have been bad this week, but you're smiling." "You say things have been bad this week, but you're smiling" is an open-ended, nonjudgmental response that points out incongruity between the client's verbal and nonverbal communication. Asking the client to share, remaining silent but making a note of the incongruity, or noting that it has been a bad week for several of the group's members will not help the client recognize the incongruity.

30 y/o female with depression, poor eating habits, and who is underweight comes to the clinic and expresses suicidal ideations. Which nursing diagnosis should be the nurses first priority A. risk for suicide B. chronic low self-esteem C. imbalanced nutrition D. constipation

A. risk for suicide Nursing diagnoses are numerous. Risk for suicide is always the priority diagnosis when suicidal ideation is present. Other common nursing diagnoses are chronic low self-esteem, imbalanced nutrition, constipation, disturbed sleep pattern, ineffective coping, and disabled family coping.

A client reports to the primary healthcare provider with a complaint of becoming panicked and having irrational fear of public talking. Which drug does the nurse anticipate to be prescribed by the primary healthcare provider? a. Buspirone b. Alprazolam c. Diazepam e. Lorazepam

b. Alprazolam Alprazolam (a benzodiazepine) is a short-acting anxiolytic drug used to treat those clients with panic disorders and the irrational fear of talking openly in public (agoraphobia). Buspirone, an anxiolytic drug that is different both chemically and pharmacologically from the benzodiazepines, is always administered on a scheduled basis (not "as-needed") for the treatment of anxiety. Diazepam is an anxiolytic drug commonly prescribed for the treatment of anxiety but has generally been replaced by short-acting benzodiazepines. Lorazepam is an intermediate-acting anxiolytic drug used in the treatment of acutely agitated clients.

The nurse is providing instructions to a client who is on isocarboxazid for depression. Which statements made by the client indicate effective learning? Select all that apply. A. "I will include yogurt in my diet." B. "I will avoid soy sauce in my diet." C. "I will avoid pepperoni in my diet." D. "I will include cream cheese in my diet." E. "I will avoid fermented bean curds in my diet.

A. "I will include yogurt in my diet." D. "I will include cream cheese in my diet." E. "I will avoid fermented bean curds in my diet. Isocarboxazid is a monoamine oxidase (MAO) inhibitor used to treat depression. Clients on MAOIs should avoid foods containing high amounts of tyramine. Yogurt and cream cheese are foods containing low to no tyramine content. Fermented bean curds are high tyramine-containing foods that should be avoided. Soy sauce and pepperoni are high tyramine foods that should be avoided

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior? A.Keep the client under close observation. B. Arrange for the client to have more visitors. C. Engage the client in preliminary discharge planning. D. Observe the client for side effects of the medication

A.Keep the client under close observation. As the client's motivation and energy return, the likelihood that suicidal ideation will be acted out increases. There are no data regarding visitation rights; the priority concern is the greater risk for suicide. Although engaging the client in preliminary discharge planning eventually will be done, the priority is determining the potential for suicide. Although the client should be observed for side effects of the medication, the greater risk of suicide takes precedence.

A nurse is concerned when an 11-month-old infant is brought to the pediatric clinic weighing 9 lb 3 oz (4167 g). The nurse suspects that the infant is suffering from physical and emotional neglect. What observations lead the nurse to suspect maltreatment? Select all that apply. A. Stranger anxiety B. Inappropriate clothing C. Social unresponsiveness D. Frequent rocking motions E. Adequate personal hygiene

B. Inappropriate clothing C. Social unresponsiveness D. Frequent rocking motions Stranger anxiety begins around 5 to 6 months, when infants become responsive to the caregivers who have met both physical and emotional needs. When strangers speak to them or reach out to hold them they seem fearful, cling to the caregiver, and cry. Infants whose needs have not been met adequately have no reason to be fearful of others. A typical sign of physical neglect is the wearing of dirty clothes or clothing that is not suitable to the environment. The infant who has not experienced social responsiveness from the caregiver has not learned how to be socially responsive to others. Infants who experience emotional deprivation resort to self-stimulating behaviors in an effort to meet their emotional needs. Infants who experience physical neglect are more likely to be unclean, with signs of unattended skin lesions such as diaper rash or bruises.

Which drug is used to treat both generalized anxiety disorder and depression? A. Fluoxetine B. Bupropion C. Duloxetine D. Mirtazapine

C. Duloxetine Duloxetine is an antidepressant drug used to treat both generalized anxiety disorder and depression. Fluoxetine is used to treat depression. Bupropion is used to treat depression and also aid in smoking cessation. Mirtazapine is used in the treatment of depression and also helpful in reducing the adverse sexual side effects in the male client receiving selective serotonin reuptake inhibitors therapy.

The mother of an infant with Down syndrome asks the nurse what causes the disorder. Before responding, the nurse recalls that the genetic factor of Down syndrome results from what? A. An intrauterine infection B. An X-linked genetic disorder C. Extra chromosomal material D. An autosomal recessive gene

C. Extra chromosomal material Down syndrome (trisomy 21) results from extra chromosomal material on chromosome 21. Down syndrome does not result from a maternal infection. Down syndrome is not related to an X-linked or Y-linked gene. An autosomal recessive gene is not the cause of Down syndrome, although translocation of chromosomes 15 and 21 or 22 is a genetic aberration found in some children with Down syndrome.

A nurse is caring for a 42-year-old client who is scheduled for an amniocentesis during the fifteenth week of gestation because of concerns regarding Down syndrome. What other fetal problem does an examination of the amniotic fluid reveal at this time? A. Diabetes B. Lung maturity C. Cardiac anomalies D. Errors of metabolism

D. Errors of metabolism Inherited errors of metabolism may be detected if marker genes for a disease such as Tay-Sachs and thalassemia are present. Fetal diabetes and cardiac disorders cannot be detected with amniocentesis. Fetal lung maturity cannot be determined until after 35 weeks' gestation.

To maximize the therapeutic effect, which lifestyle practice should the nurse discourage for a patient who has been recently prescribed an antianxiety medication? a. Eating high protein foods. b. Using acetaminophen without first discussing it with a healthcare provider c. Taking medications after eating dinner or while having a bedtime snack d. Buying a large coffee with sugar and extra cream each morning on the way to work

d. Buying a large coffee with sugar and extra cream each morning on the way to work

A client who suspects that she is 6 weeks pregnant appears mildly anxious as she is waiting for her first obstetric appointment. What symptom of mild anxiety does the nurse expect this client to experience? a. Dizziness b. Breathlessness c. Abdominal cramps d. Increased alertness

d. Increased alertness Increased alertness is an expected common behavior that occurs in new or different situations when a person is mildly anxious. Dizziness, breathlessness, and abdominal cramps are all common signs of moderate to severe anxiety.

(pharm book ) Patient teaching for a patient receiving an MAOI would include instructions to avoid which food product? a. Orange juice b. Milk c. Shrimp d. Swiss cheese

d. Swiss cheese

Which nursing intervention focuses on managing a common characteristic of major depressive disorder associated with the older population? a. Conducting routine suicide screenings at a senior center. b. Identifying depression as a natural, but treatable result of aging. c. Identifying males as being at a greater risk for developing depression. d. Stressing that most individuals experience just a single episode of major depression in a lifetime.

a. Conducting routine suicide screenings at a senior center.

Which characteristic identified during an assessment serves to support a diagnosis of disruptive mood dysregulation disorder? Select all that apply. a. Female b. 7 years old c. Comorbid autism diagnosis d. Outbursts occur at least once a week e. Temper tantrums occur at home and in school

b. 7 years old c. Comorbid autism diagnosis e. Temper tantrums occur at home and in school The basic symptoms of disruptive mood dysregulation disorder are constant and severe irritability and anger in individuals between the ages of 6 and 18. Onset is before age 10. Temper tantrums with verbal or behavioral outbursts out of proportion to the situation occur at least three times a week. Sometimes children and adolescents with this problem can maintain control in certain settings such as school. To be diagnosed with disruptive mood dysregulation disorder, individuals need to exhibit the irritability, anger, and temper tantrums in at least two of these settings: home, school, and with peers. It is more common in males than females

A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do? a. Distract the client, which will help the client forget about touching the chairs b. Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in c. Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one d. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed

d. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed It is important to set limits on the behavior, but it is also important to involve the client in the decision-making. Distracting the client, which will help the client forget about touching the chairs, is nontherapeutic; rarely can a client be distracted from a ritual when anxiety is high. Encouraging the client to continue touching the chairs for as long he desires until fatigue sets in is a nontherapeutic approach; some limits must be set by the client and nurse together. Removing chairs from the hall, thereby relieving the client of the necessity of touching every other one, will increase the client's anxiety because the client uses the ritual as a defense against anxiety.

After a child's visit to a healthcare provider, the parent tells the nurse, "I'm so upset! The doctor prescribed an antidepressant!" What is the best response by the nurse? A. "Tell me more about what's bothering you." B. "Weren't you told why your child needs an antidepressant?" C. "You need to speak with the healthcare provider about your concerns." D. "Are you sure it's an antidepressant and not a drug for attention deficit disorder?"

A. "Tell me more about what's bothering you." "Tell me more about what's bothering you" provides an opportunity to explore the parent's feelings. It is the nurse's responsibility, not the healthcare provider's, to assess the parent's concerns before planning further interventions. "Weren't you told why your child needs an antidepressant?" is a confrontational response that may put the parent on the defensive. "Are you sure it's an antidepressant and not a drug for attention deficit disorder?" is a judgmental, nontherapeutic response that may worsen the parent's concerns.

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? A. Anxiety and guilt B. Anger and hostility C. Embarrassment and shame D. Hopelessness and powerlessness

A. Anxiety and guilt Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse? A. Encouraging him to express his feelings about the situation B. Telling him to schedule an appointment with the gynecologist C. Asking whether he can afford a home health aide for several weeks D. Informing him that he should seek emergency intervention for his wife

D. Informing him that he should seek emergency intervention for his wife The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time. The wife has an emotional, not physiologic, problem at this time. Asking whether the family can afford a home health aide for several weeks is not the priority at this time; the wife's emotional condition is the priority.

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Which questions does the nurse ask? Select all that apply. A. "What brought you here for treatment today?" B. "What do you believe is the cause of your depression?" C. "Does religion have a role in your perception of health and wellness?" D. "Do you have insurance that includes coverage of mental health issues?" E. "Have you ever sought treatment for a mental health problem previously?"

A. "What brought you here for treatment today?" B. "What do you believe is the cause of your depression?" C. "Does religion have a role in your perception of health and wellness?" E. "Have you ever sought treatment for a mental health problem previously?" Determining the client's perception of the problem is an appropriate question that allows cultural factors to be included. Encouraging the client to discuss the problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.

When the nurse is managing the care of an acutely depressed client, which intervention demonstrates that the nurse recognizes the client's fundamental mental health need? A. Role modeling a hopeful attitude regarding life and the future B. Sharing that life has presented depressing situations for all of us at times C. Devoting time with the client and trying to focus on happy, positive memories D. Identifying the client's personal weaknesses and designing interventions to strengthen them

A. Role modeling a hopeful attitude regarding life and the future Role modeling has been shown to be an excellent tool in molding adaptive behavior. Depression affects the individual's ability to see hope in the future, and role modeling will help provide adaptation to similar feelings. Affirming that everyone has depressive situations in their lives does not foster a positive response in the depressed client. Reminiscing about happier times and events is likely to highlight the client's current loss of happiness rather than foster positive feelings. The depressed client generally has low self-esteem and is often too tired to engage in physical activities. When a client is depressed, the nurse should identify the client's personal strengths, not weaknesses, and focus on interventions to reinforce those strengths. Focusing on a client's weaknesses when the client is already depressed may initiate a deeper depression.

Which teratogens affecting fetal growth and development should the nurse include in a teaching session for pregnant clients? Select all that apply. A. Rubella B. Varicella C. Swordfish D. Phenytoin E. Acetaminophen

A. Rubella B. Varicella C. Swordfish D. Phenytoin Teratogens are noxious materials such as viruses, chemicals, and drugs that pass from mother to child during pregnancy that can affect fetal growth and development. Rubella, varicella, swordfish (due to high mercury content), and phenytoin are all teratogens that the nurse should educate pregnancy clients to avoid. Acetaminophen is not a teratogen.

A pregnant woman continues consuming alcohol during pregnancy. Which teratogenic effects might be seen in the fetus or neonate? Select all that apply. A. Stillbirth B. Ebstein anomaly C. Neural tube defects D. Spontaneous abortion E. Intellectual disabilities

A. Stillbirth D. Spontaneous abortion E. Intellectual disabilities Prolonged fetal exposure to alcohol may cause a stillbirth. A spontaneous abortion may occur if the pregnant woman consumes alcohol in excess amounts. Intellectual disabilities may be seen in the neonate if it is exposed to alcohol in the fetal stage. Ebstein anomaly is caused by lithium exposure during pregnancy. Neural tube defects may be due to exposure to antiseizure drugs during pregnancy.

A nurse spends time in individual sessions helping a depressed, suicidal client verbalize feelings. For what themes should the nurse particularly listen? Select all that apply. A. Anger B. Control C. Isolation D. Dominance E. Hopelessness F. Indecisiveness

C. Isolation E. Hopelessness Feelings of isolation compound feelings of hopelessness and helplessness and may provide the client with the impetus to act on suicide ideation. The main factor leading to acting on suicidal impulses is the feeling of hopelessness, that there is nothing to live for. Anger may be associated with depression; however, a depressed person usually does not have the energy to act out suicidal ideation. The struggle for control or dominance is not an important risk factor for suicide. Indecisiveness may be associated with depression, but an indecisive individual is usually unable to make the decision to commit suicide.

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? A. Young adult who is acutely psychotic B. Adolescent who was recently sexually abused C. Older single man just found to have pancreatic cancer D. Middle-age woman experiencing dysfunctional grieving

C. Older single man just found to have pancreatic cancer Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of older single men with chronic health problems.

Margaret, age 68, is a widow of 6 months. Since her husband dies, her sister reports that Margaret has become socially withdrawn, has lost weight, and does little more each day than visit the cemetery where her husband was buried. She told her sister today that she "didn't have anything more to live for." She has been hospitalized with major depressive disorder. The PRIORITY nursing diagnosis for Margaret would be: A. Imbalanced nutrition: less than body requirements B. Complicated grieving C. Risk for suicide D. social isolation

C. Risk for suicideThis client is indicating thoughts of suicide. Safety should always be considered the priority with the other diagnoses being addressed after the initial threat has passed.

A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? A. Undoing B. Projection C. Suppression D. Intellectualization

C. Suppression Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.

A client comes to the clinic for a 6-week postpartum check-up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information? A. Providing information about a local support group B.Explaining that it is normal to feel depressed after childbirth C.Asking the client questions, using a postpartum depression scale D. Suggesting that the client find someone who can take care of the baby for 24 hours

C.Asking the client questions, using a postpartum depression scale A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. The most widely used and validated tools are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Although providing community resources of a local support group may be helpful, it is not useful in assessing the client's current emotional status. Although postpartum blues caused by hormonal changes soon after pregnancy might be common, feelings of depression and fatigue 6 weeks after childbirth is a matter of concern. The client may not have anyone else who can provide child care, or the client may not follow through on the recommendation. In addition, this intervention does not provide any information on the client's current emotional status.

A client with recurrent episodes of depression comes to the mental health clinic for a routine follow-up visit. The nurse suspects that the client is at increased risk for suicide. What is a contributing factor to the client's risk for suicide? A. Psychomotor retardation B. Decreased physical activity C. Deliberate thoughtful behavior D. Overwhelming feelings of guilt

D. Overwhelming feelings of guilt Overwhelming feelings of guilt contribute to the client's risk for suicide. The client may ruminate over past or current failings, and extreme guilt can assume psychotic proportions. Psychomotor retardation and decreased physical activity are clinical findings associated with depression and usually do not lead to suicide because the client does not have the energy for self-harm. Impulsive behaviors, not deliberate thoughtful behaviors, contribute to the client's risk for suicide.