Unit 4: Bipolar, Depression, + Personality Disorders NCLEX-RN questions

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive

1 The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.

Which statement made by a severely depressed client requires the nurse's immediate attention? 1."Feeling better really isn't important to me anymore." 2."No one can really understand what I've had to deal with." 3."I really don't like the way that new depression pill makes me feel." 4."I've not been the least bit interested in socializing since my divorce."

1 The suicidal client may subtly express the intention to harm oneself in the form of a covert suicidal threat. The statement in option 1 should receive the nurse's priority attention because it is directly related to the client's safety. The remaining options are not related to safety as directly.

A hospitalized client is started on phenelzine for the treatment of depression. The nurse should instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1.Figs 2.Yogurt 3.Crackers 4.Aged cheese 5.Tossed salad 6.Oatmeal raisin cookies

3,5 Phenelzine is a monoamine oxidase inhibitor (MAOI). The client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1.Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that he or she will not be able to attend any future group sessions

1 Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.

A client with depression verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response? 1.Tell the client that this is not true, that we all have a purpose in life. 2.Identify recent behaviors or accomplishments that demonstrate the client's skills. 3.Reassure the client that the nurse knows how the client is feeling and that things will get better. 4.Remain with the client and sit in silence. This will encourage the client to verbalize feelings.

2 Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Silence may be interpreted as agreement. Avoid options that give advice and devalue the client's feelings.

A client diagnosed with bipolar disorder is prescribed lithium carbonate. The nurse who administers the medication knows that lithium is used primarily to treat which condition? 1.Suicidal ideations 2.The manic phase of bipolar disease 3.Both depressive and manic episodes 4.The depressive phase of bipolar disease

2 Lithium is an antimanic medication and is used to treat the manic phase of a manic-depressive disorder. The remaining options are incorrect

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1.Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed

3 A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations

A client diagnosed with bipolar mood disorder has been given a prescription for carbamazepine. The nurse teaching the client about medication side and adverse effects instructs the client to notify the primary health care provider if which symptom develops? 1.Nausea 2.Dizziness 3.Sore throat 4.Drowsiness

3 Carbamazepine may be prescribed for a client with a bipolar mood disorder to provide symptomatic control of the disorder. An adverse effect of carbamazepine is blood dyscrasia. With development of a fever, sore throat, mouth ulcerations, unusual bleeding, bruising, or joint pain, the primary health care provider should be notified because these findings may indicate a blood dyscrasia. Nausea, dizziness, drowsiness, and vomiting are frequent side effects associated with the medication.

A client diagnosed with depression has a prescription for sertraline. The nurse should withhold the medication and question the prescription if the client has a history of which disorder? 1.Diabetes mellitus 2.Myocardial infarction 3.Phenelzine sulfate use 4.Irritable bowel syndrome

3 Sertraline is a selective serotonin reuptake inhibitor. Fatal reactions may occur if sertraline is administered concurrently with phenelzine, a monoamine oxidase inhibitor (MAOI). MAOIs should be stopped at least 14 days before initiation of sertraline therapy. Likewise, sertraline should be stopped at least 14 days before initiation of MAOI therapy. The other options are incorrect.

A client in a manic state presents to the dayroom only partially dressed and is making sexual remarks and gestures toward the staff and other clients. Which is the initial nursing action? 1.Instruct the client to go back to his room. 2.Inform the client that such behavior will not be accepted. 3.Instruct the other clients to go to their rooms immediately. 4.Escort the client to his room to get appropriately dressed.

4 A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. Use of a quiet, firm approach and distracting the client (walking to his room and assisting him in getting dressed) will achieve the goal of having him dressed appropriately while preserving his psychosocial integrity. While restating boundaries is appropriate, the initial task relates to controlling inappropriate behaviors while protecting the client. Telling the other clients to go to their rooms immediately is inappropriate and does not address the client's behavior.

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement? 1."I hope I am going to like my new counselor." 2."I sure hope I will still be productive at work." 3."I am going to keep a close check on any stress I have in my life." 4."I will take the medicine until I am sure I can handle my own problems.

4 The client does not demonstrate an understanding of the continued need for medication and suggests that the illness can be controlled by decreasing stress. The remaining options are common concerns of a client on discharge but do not indicate the need for further teaching.

Which interventions should the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply. 1.Assisting the client to identify and test negative cognition 2.Assisting the client to participate in the treatment process 3.Assisting the client to develop alternative thinking patterns 4.Assisting the client to rehearse new cognitive and behavioral responses 5.Assisting the client with the administration of antidepressant medications 6.Assisting the client's family to participate in group therapy on a regular basis

1,2,3,4 The goal of cognitive-behavioral therapy is to change the way clients think and thus relieve the depressive syndrome. This is accomplished by assisting the client to identify and test negative cognition, participate in the treatment process, develop alternative thinking patterns, and rehearse new cognitive and behavioral responses. Although some clients are treated with antidepressant medications, this is not a component of cognitive-behavioral therapy. The focus of this therapy is on the client, not the family.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client. 2.Ensure that the client knows that they are not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable

1,3,4,6 Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that she or he is not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules and informing the client that she or he will not be allowed to attend therapy groups is a violation of a client's rights.

A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how should the nurse administer the dose? 1.On an empty stomach 2.At the same time each evening 3.Evenly spaced around the clock 4.As needed when the client complains of depression

2 Sertraline is classified as an antidepressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline is not prescribed for use as needed.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1.Chess 2.Writing 3.Board games 4.Group exercise

2 Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them or are group activities and should be avoided because they can stimulate aggression and increase psychomotor activity.

A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? 1.Institute the unit's suicide precaution protocol. 2.Alert the client's psychiatrist of these changes immediately. 3.Notify the staff of these observations at today's team meeting. 4.Ask the client directly about the presence of any suicide-related thoughts.

4 A sudden improvement in a depressed client's mood may indicate that the client has decided to commit suicide. The most direct way to validate the nurse's impression is to ask the client directly about suicidal ideation or plans. The other options are not the most appropriate initial nursing intervention.

The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family? 1.Brain anomalies that are responsible for this disorder 2.Signs that indicate the client may be considering suicide 3.The importance benzodiazepines play in the management of this disorder 4.The possibility that the client will experience medication-induced tinnitus

2 Suicide is the most serious concern for clients with mood disorders. Early identification of behaviors that reflect the client's suicidal mind-set is vital to minimizing the risk of self-injury and/or death. Mood disorders are not typically a result of brain anomalies. Benzodiazepines are not the medication classification of choice for treating mood disorders. Tinnitus is not a typical side effect of antidepressant medication therapy.

A client reported to the nurse that he has been taking an extra dose of his tricyclic antidepressant for a week because he has been feeling more depressed than usual. Hearing this, the nurse knows which are the most appropriate actions to take? Select all that apply. 1.Tell the client that taking an extra dose is ok as long as it is not longer than 1 week. 2.Re-educate the client because tricyclic antidepressant overdoses can be life threatening. 3.Advise the client to take in more liquids while an extra dose is being taken because dry mouth is a side effect of this medication. 4.Tell the client to continue taking the extra dose; the client knows how he is feeling and can stop the extra dose when he is feeling more himself. 5.Inform the client that if he experiences any symptoms of dysrhythmias, dry mouth, confusion, agitation, or hallucinations, he should seek medical attention right away.

2,5 A tricyclic antidepressant overdose can be life threatening. Signs and symptoms include dysrhythmias, including tachycardia, intraventricular blocks, complete atrioventricular block, and ventricular fibrillation; hypothermia; flushing; dry mouth; dilation of the pupils; confusion, agitation, and hallucinations; and seizures followed by coma. Medical attention should be sought if any of the following occur. Extra doses are not appropriate and can lead to overdose. Advising the client to take in more liquids will not prevent overdose. The client needs re-education.

A client diagnosed with depression is prescribed amitriptyline hydrochloride. During the initial phases of treatment, the client's care plan should include which nursing intervention? 1.Obtain daily drug blood levels. 2.Provide the client a tyramine-free diet. 3.Assess the client for anticholinergic effects. 4.Obtain postural blood pressure prior to each medication administration

4 Amitriptyline hydrochloride is a tricyclic antidepressant. A common side/adverse effect is orthostatic blood pressure changes, which can produce hypotension and tachycardia. The tachycardia can be frightening to the client, and the hypotension is dangerous because it may result in dizziness and falling. The client must be instructed to move slowly from a lying to a sitting or standing position to avoid injury if these changes are experienced. The client may experience some side/adverse effects, such as sedation, dry mouth, constipation, and blurred vision (anticholinergic effects). However, these effects are transient and will diminish with time. A tyramine-free diet is initiated for a client on a monoamine oxidase inhibitor. Blood levels are required for the client taking lithium.

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client? 1.Isolating self 2.Inability to cope 3.Low self-esteem 4.Risk for self-harm

4 Clients with borderline personality disorder are most often hospitalized because of impulsive attempts at self-mutilation or suicide. The nursing intervention of constant close observation is usually initiated to protect the client from impulsive behavior. If any of the other options exist, they are of lesser priority.

A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? 1.Teach self-grooming skills. 2.Reward cleanliness with unit privileges. 3.Monitor the adequacy of the antipsychotic dosage. 4.Encourage frequent fluid intake and a high-fiber diet.

4 Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question in combination with antipsychotic medications are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.

The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion? 1."I know now that I can't be all things to all people all the time." 2."It is important for me to take my medications just as prescribed." 3."It's been good to learn better ways to deal with the stresses in my life." 4."I know that I won't become depressed again as long as I reduce my stressors."

4 Depression is a mood disorder that can be a recurrent illness. While stress reduction is a factor, managing stress is not the only strategy for avoiding depression. The client must learn to recognize symptoms of the disorder and to know who and when to call to resume more active treatment. Each of the incorrect options indicates a successful coping mechanism or health-promoting behavior

In formulating a discharge teaching plan, the nurse should include which precaution for a client with bipolar disorder who is prescribed lithium carbonate therapy? 1.Avoid soy sauce, wine, and aged cheese. 2.Have the blood lithium level checked every 2 weeks. 3.Take the medication only as prescribed to avoid becoming addicted. 4.Check with the psychiatrist before using any over-the-counter medications.

4 Lithium is a mood stabilizer and a medication to treat bipolar disorder. Its exact mechanism of action remains speculative; however, equilibrium of sodium and potassium must be maintained at the intracellular membrane to maintain therapeutic effects. Lithium competes with sodium in the cell. Many over-the-counter medications contain sodium, and often prescription medications (diuretics) change the sodium-potassium ratios of the cell, thereby affecting lithium concentrations so that it is more difficult to achieve therapeutic levels of the medication. Food restriction (tyramine-restricted diet) is associated with monoamine oxidase inhibitors. Lithium blood levels are recommended for the client taking lithium, but these tests generally are prescribed every 3 to 4 months. Lithium is not addictive.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1.Incessant talking and sexual innuendoes 2.Grandiose delusions and poor concentration 3.Outlandish behaviors and inappropriate dress 4.Nonstop physical activity and poor nutritional intake

4 Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

The primary health care provider is planning to prescribe a medication for a client with major depression. Which medication should the nurse expect to be prescribed? 1.Diazepam 2.Lorazepam 3.Phenobarbital 4.Paroxetine hydrochloride

4 Paroxetine is an antidepressant used in the treatment of major depression. Diazepam and lorazepam are benzodiazepines and are used to treat anxiety. Phenobarbital is a barbiturate used for the short-term treatment of insomnia

During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries? 1."Thank you, the perfume was a gift." 2."Your comment is really inappropriate." 3."Neither my hair nor my perfume is the focus of today's session." 4."The focus of today's session is on your issues, so let's get started."

4 The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle or those that are a social response and could be misinterpreted by the client.

A client diagnosed with depression and prescribed tranylcypromine sulfate has been instructed on the appropriate diet. The nurse determines that the client understands the diet if which foods are selected from the dietary menu? 1.Pickled herring, french fries, and milk 2.Pepperoni pizza, salad, and a cola drink 3.Roasted chicken, roasted potatoes, and beer 4.Fried haddock, baked potato, and a cola drink

4 Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. A tyramine-restricted diet is required while on this medication to avoid hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausage (salami, pepperoni, bologna). In addition, figs; bananas; aged cheese; yogurt and sour cream; beer, red wine, and other alcoholic beverages; soy sauce; yeast extract; chocolate; caffeine; and aged, pickled, fermented, or smoked foods need to be avoided.

Which activity should the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation? 1.Playing checkers with members of the staff 2.Reading in a quiet, low-stimulus environment 3.Engaging in a card game with other clients on the unit 4.Attending a clay-molding class that is scheduled for today

4 When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.

A client is brought into the emergency department for suspected tricyclic antidepressant overdose. Place the actions that the nurse should take in order of priority. All options must be used. 1.Administer oxygen 2.Check and monitor vital signs. 3.Obtain an electrocardiogram. 4.Check airway and maintain patency. 5.Prepare gastric lavage with activated charcoal. 6.Prepare to administer prescribed medications.

4,1,2,3,5,6 A tricyclic antidepressant overdose can be life threatening. Signs and symptoms include dysrhythmias, including tachycardia, intraventricular blocks, complete atrioventricular block, and ventricular fibrillation; hypothermia; flushing; dry mouth; dilation of the pupils; confusion, agitation, and hallucinations; and seizures followed by coma. The immediate action is to check the airway and institute measures such as oxygen to maintain an adequate oxygenation level. Vital signs are checked and monitored, and an electrocardiogram is obtained to check for dysrhythmias. Gastric lavage with activated charcoal is done to prevent further absorption of the medication. Medications to counteract anticholinergic effects may be prescribed, as well as antidysrhythmics. The nurse documents the event, actions taken, and the client's response.