Chap 15 and 16

A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply. a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids. d. Restrain the patient in bed with padded limb restraints. e. Assist the patient to prepare an advance directive.

a. Administer pretreatment medication 30 to 45 minutes before treatment. b. Withhold food and fluids for a minimum of 6 hours before treatment. c. Remove dentures, glasses, contact lenses, and hearing aids. The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment.

Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. Converses without interrupting; clothing matches; participates in activities. b. Irritable, suggestible, distractible; napped for 10 minutes in afternoon. c. Attention span short; writing copious notes; intrudes in conversations. d. Heavy makeup; seductive toward staff; pressured speech.

a. Converses without interrupting; clothing matches; participates in activities. The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A patient diagnosed with bipolar disorder commands other patients, Get me a book. Take this stuff out of here, and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse. a. Distraction: Lets go to the dining room for a snack. b. Humor: How much are you paying servants these days? c. Limit setting: You must stop ordering other patients around. d. Honest feedback: Your controlling behavior is annoying others.

a. Distraction: Lets go to the dining room for a snack. The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger.

A student nurse caring for a patient diagnosed with major depressive disorder reads in the patients medical record, This patient shows vegetative signs of depression. Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

a. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self.

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, Ill punch you, munch you, crunch you, while twirling and shadowboxing. Then the patient says gaily, Do you like my scarves? Herethey are my gift to you. How should the nurse document the patients mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

a. Labile and euphoric The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patients mood. A high level of suspicion is not evident.

A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurses most effective approach to communication. a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

a. Make observations. Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurses presence. Direct questions may make the patient feel that the encounter is an interrogation. Open- ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness.

A nurse teaching a patient about a tyramine-restricted diet would approve which meal? a. Mashed potatoes, ground beef patty, corn, green beans, apple pie b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

a. Mashed potatoes, ground beef patty, corn, green beans, apple pie The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict the intake of processed foods.

a. Offer laxatives, if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.

A patient tells the nurse, I am so ashamed of being bipolar. When Im manic, my behavior embarrasses my family. Even if I take my medication, theres no guarantee I wont have a relapse. I am such a burden to my family. These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

a. Powerlessness c. Chronic low self-esteem

A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply. a. Provide structure b. Limit credit card access c. Encourage group social interaction d. Limit work to half days e. Monitor the patients sleep patterns

a. Provide structure b. Limit credit card access e. Monitor the patients sleep patterns A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania.

A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. Risk for injury Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patients physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury.

Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated project was a failure, just like me. c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, I feel tired all the time.

a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding.

An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training b. Relaxation training classes c. Use of complementary therapy d. Learning desensitization techniques

a. Social skills training Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patients support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias.

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Supporting physiologic stability b. Reducing disorientation and confusion c. Monitoring pupillary responses d. Assisting the patient to identify and test negative thoughts

a. Supporting physiologic stability During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Monitoring pupillary responses is not a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.

A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient himself or herself to a pressured work schedule.

a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient himself or herself to a pressured work schedule is less relevant than the correct rationale.

A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, I took a few extra tablets earlier in the day and now I feel bad. Which aspects of the nursing assessment are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Increased suicidal ideation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

a. Vital signs d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected.

A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, I dont think I can keep taking these pills. They make me so dizzy, especially when I stand up. The nurse should: a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient. d. teach the patient how to use pursed-lip breathing.

a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks. Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Pursed-lip breathing is irrelevant.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salt and fluids in the diet. Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information.

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

a. meals. Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

a. several factors, including genetics, are implicated. At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances.

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, No one cares about me anymore. Im not worth anything. Select an appropriate initial outcome for the nursing diagnosis: Situational low self-esteem, related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date) . b. consent to take antidepressant medication regularly by (date) . c. initiate social interaction with another person daily by (date) . d. identify two personal behaviors that alienate others by (date) .

a. verbalize realistic positive characteristics about self by (date) . Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

a. within therapeutic limits The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurses best response. a. A high proportion of patients diagnosed with bipolar disorders are found among creative writers. b. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder. c. Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses. d. More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds.

b. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder. Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission of bipolar disorder.

During a psychiatric assessment, the nurse observes a patients facial expressions that are without emotion. The patient says, Life feels so hopeless to me. Ive been feeling sad for several months. How should the nurse document the patients affect and mood? a. Affect depressed; mood flat b. Affect flat; mood depressed c. Affect labile; mood euphoric d. Affect and mood are incongruent

b. Affect flat; mood depressed Mood is a persons self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.

A patient says to the nurse, My life does not have any happiness in it anymore. I once enjoyed holidays, but now theyre just another day. How would the nurse document the complaint? a. Vegetative symptom b. Anhedonia c. Euphoria d. Anergia

b. Anhedonia Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Vegetative symptoms refer to somatic changes associated with depression. Euphoria refers to an elated mood. Anergia means without energy.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

b. Disturbed sleep pattern Patients diagnosed with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid volume.

A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

b. Disturbed thought processes c. Sleep deprivation People with mania are hyperactive and often do not take the time to eat and drink properly. Their high levels of activity consume calories; therefore deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, Ive had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do? The nurse should advise the patient: a. Restrict oral fluids for 24 hours and stay in bed. b. Have someone bring you to the clinic immediately. c. Drink a large glass of water with 1 teaspoon of salt added. d. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.

b. Have someone bring you to the clinic immediately. The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patients symptoms. Restricting oral fluids will make the situation worse.

A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

b. Hold a staff meeting to discuss consistency and limit-setting approaches. When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Criteria for seclusion have not been met.

A patient experiencing acute mania waves a newspaper and says, I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes. Select the nurses most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.

b. Invite the patient to sit with the nurse and look at new fashion magazines. Situations such as this offer an opportunity to use the patients distractibility to the staffs advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patients need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

A patient diagnosed with major depressive disorder tells the nurse, Bad things that happen are always my fault. To assist the patient in reframing this overgeneralization, the nurse should respond: a. I really doubt that one person can be blamed for all the bad things that happen. b. Lets look at one bad thing that happened to see if another explanation exists. c. You are being exceptionally hard on yourself when you say those things. d. How does your belief in fate relate to your cultural heritage?

b. Lets look at one bad thing that happened to see if another explanation exists. By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses are judgmental, irrelevant to an overgeneralization, and cast doubt without requiring the patient to evaluate the statement.

At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. Extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

b. Neutral walls with pale, simple accessories The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury.

A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?a. Monitor physiologic functioning b. Provide a subdued environment c. Supervise personal hygiene d. Observe for mood changes

b. Provide a subdued environment All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest.

A patient diagnosed with major depressive disorder repeatedly tells staff members, I have cancer. Its my punishment for being a bad person. Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b. Risk for suicide A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.

When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on the patients behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

b. Set limits on the patients behavior as necessary. This intervention provides support through the nurses presence and provides structure as necessary while the patients control is tenuous. Acting out may lead to the loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, Do I have to keep taking this lithium even though my mood is stable now? Select the nurses most appropriate response. a. You will be able to stop the medication in approximately 1 month. b. Taking the medication every day helps prevent relapses and recurrences. c. Usually patients take this medication for approximately 6 months after discharge. d. Its unusual that the health care provider has not already stopped your medication.

b. Taking the medication every day helps prevent relapses and recurrences. Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. The incorrect options offer incorrect or misleading information.

A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate? a. You look nice this morning. b. You are wearing a new shirt. c. I like the shirt youre wearing. d. You must be feeling better today.

b. You are wearing a new shirt. Patients with depression usually see the negative side of things. The meaning of compliments may be altered to I didnt look nice yesterday or They didnt like my other shirt. Neutral comments such as an observation avoid negative interpretations. Saying You look nice or I like your shirt gives approval (nontherapeutic techniques). Saying You must be feeling better today is an assumption, which is nontherapeutic.

A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

b. bring hyperactivity under rapid control. Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithiums antimanic activity nor minimize the side effects. Lithium is used for long-term control.

A priority nursing intervention for a patient diagnosed with major depressive disorder is: a. distracting the patient from self-absorption. b. carefully and inconspicuously observing the patient around the clock. c. allowing the patient to spend long periods alone in self-reflection. d. offering opportunities for the patient to assume a leadership role in the therapeutic milieu.

b. carefully and inconspicuously observing the patient around the clock. Approximately two thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit.

This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: a. ask staff for assistance with feeding within 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at mealtime within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day. High-calorie, high-protein food supplements will provide the additional calories needed to offset the patients extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis.

A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. b. hypertensive crisis. c. cardiac dysrhythmia. d. cardiogenic shock.

b. hypertensive crisis. Patients taking MAOIs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure.

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to: a. avoid exposure to bright sunlight. b. report increased suicidal thoughts. c. restrict sodium intake to 1 g daily. d. maintain a tyramine-free diet.

b. report increased suicidal thoughts. Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, apple The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could eat on the run. The foods in the incorrect options cannot be eaten without utensils.

A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. Stop that! No one did anything to provoke an attack by you. b. If you do that one more time, you will be secluded immediately. c. Do not hit anyone. If you are unable to control yourself, we will help you. d. You know we will not let you hit anyone. Why do you continue this behavior?

c. Do not hit anyone. If you are unable to control yourself, we will help you. When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking why does not provide for environmental safety.

The admission note indicates a patient diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation Anhedonia refers to the inability to find pleasure or meaning in life; thus planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is the lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.

A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficit and sad mood

c. Poor judgment and hyperactivity Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania.

A patients employment is terminated and major depressive disorder results. The patient says to the nurse, Im not worth the time you spend with me. Im the most useless person in the world. Which nursing diagnosis applies? a. Powerlessness b. Defensive coping c. Situational low self-esteem d. Disturbed personal identity

c. Situational low self-esteem The patients statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to justify the other diagnoses.

A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares. The nurse should advise the patient: a. Go to the nearest emergency department immediately. b. Do not to be alarmed. Take two aspirin and drink plenty of fluids. c. Take one dose of the antidepressant. Come to the clinic to see the health care provider. d. Resume taking the antidepressant for 2 more weeks, and then discontinue it again.

c. Take one dose of the antidepressant. Come to the clinic to see the health care provider. The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.

A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

c. carbamazepine (Tegretol) Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes.

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, Ill throw the pool balls if anyone comes near me. The nurses first intervention is to: a. tell the patient, You need to be secluded. b. help the patient down from the table. c. clear the room of all other patients. d. assemble a show of force.

c. clear the room of all other patients. Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence.

When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

c. cognitive behavioral therapy. Cognitive behavioral therapy attempts to alter the patients dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned.

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. consults the pharmacist when selecting over-the-counter medications. d. can identify foods with high selenium content, which should be avoided.

c. consults the pharmacist when selecting over-the-counter medications. Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

A patient was started on escitalopram (Lexapro) 5 days ago and now says, This medicine isnt working. The nurses best intervention would be to: a. discuss with the health care provider the need to change medications. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptom relief.

c. explain the time lag before antidepressants relieve symptoms. Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients.

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

c. lamotrigine (Lamictal) The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

A patient experiencing acute mania undresses in the group room and dances. The nurses first intervention would be to: a. quietly ask the patient, Why dont you put on your clothes? b. firmly tell the patient, Stop dancing, and put on your clothing. c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

c. put a blanket around the patient, and walk with the patient to a quiet room. Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach.

Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. maintaining an interest in the environment. b. developing an optimistic outlook. c. self-control of distorted thinking. d. stabilizing the sleep pattern.

c. self-control of distorted thinking. The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

Lithium is prescribed for a new patient. Which information from the patients history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure

d. Congestive heart failure The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function.

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurses best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patients speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

d. Consider the need to check the lithium level. The patient may not be swallowing medications. The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of cheeking the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased.

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate? a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes pointed downward

d. Eyes pointed downward Nonverbal communication is usually considered more powerful than verbal communication. Downward-casted eyes suggest feelings of worthlessness or hopelessness.

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, No one cares about me. Im not worth anything. Which response by the nurse would be the most helpful? a. Things will look brighter soon. Everyone feels down once in a while. b. The staff here cares about you and wants to try to help you get better. c. It is difficult for others to care about you when you repeatedly say negative things about yourself. d. Ill sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon.

d. Ill sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon. Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point.

Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d. Milk Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patients family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

d. Psychoeducation During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation.

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, I feel like a failure. This baby is the root of my problems. The priority nursing diagnosis is: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence

d. Risk for other-directed violence When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.

A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth b. Blurred vision c. Nasal congestion d. Urinary retention

d. Urinary retention All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

d. arrange for one-on-one supervision. A patient who repeatedly disrobes, despite verbal limit setting, needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proved successful, considering the behavior has continued. Asking whether the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should: a. avoid forcing the issue. b. bring up the issue at the community meeting. c. calmly tell the patient, You must bathe daily. d. firmly and neutrally assist the patient with showering.

d. firmly and neutrally assist the patient with showering. When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of: a. overinvolvement. b. guilt and despair. c. interest and pleasure. d. ineffectiveness and frustration.

d. ineffectiveness and frustration. Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patients progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Guilt and despair might be observed when the nurse experiences feelings about patients because of sympathy. Interest is possible but not the most likely result. The correct response is more global than overinvolvement.