Mental Health Ch 14, 22, 24

A client 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 intake of processed foods.

A, B, C

For which clients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

A, B, C, D

A client being treated with paroxetine 50 mg po daily reports to the clinic nurse, "I took a few extra tablets earlier today and now I feel bad." Which assessments are most critical? (Select all that apply.) a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

A, D, E

What is the most therapeutic characteristics for a nurse working with a client beginning treatment for alcohol addiction to present? a. Empathetic, supportive b. Skeptical, guarded c. Cool, distant d. Confrontational

a. Empathetic, supportive

A client was diagnosed with seasonal affective disorder (SAD). During which month would this client's symptoms be most acute? a. January b. April c. June d. September

a. January

A client says, "I get in trouble sometimes because I make quick decisions and act on them." What is the nurse's most therapeutic response? a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

a. Let's consider the advantages of being able to stop and think before acting.

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the client to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

a. Refer requests and questions related to care to the case manager.

What is the priority intervention for a nurse beginning to work with a client diagnosed with a schizotypal personality disorder? a. Respect the client's need for periods of social isolation. b. Prevent the client from violating the nurse's rights. c. Teach the client how to select clothing for outings. d. Engage the client in community activities.

a. Respect the client's need for periods of social isolation

What is the priority nursing diagnosis for a client diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

a. Risk for other-directed violence

When a client first began using alcohol, two drinks produced relaxation and drowsiness. After 1 year, four drinks are needed to achieve the same response. Why has this change occurred? a. Tolerance has developed. b. Antagonistic effects are evident. c. Metabolism of the alcohol is now delayed. d. Pharmacokinetics of the alcohol have changed.

a. Tolerance has developed

During the third week of treatment, the spouse of a client in a rehabilitation program for substance abuse says, "After this treatment program, I think everything will be all right." Which remark by the nurse will be most helpful to the spouse? a. "While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol." b. "It will be important for you to structure life to avoid as much stress as you can and provide social protection." c. "Addiction is a lifelong disease of self-destruction. You will need to observe your spouse's behavior carefully." d. "It is good that you are supportive of your spouse's sobriety and want to help maintain it."

a. While sobriety solves some problems, new ones may emerge as one adjusts to living without drugs and alcohol.

A nurse taught a client about a tyramine-restricted diet. Which menu selection would the indicate the client understood the information? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

A client diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The client reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Cholinesterase inhibitor

b. Mood stabilizing medication

Which symptoms of withdrawal from opioids should the nurse assess for? a. dilated pupils, tachycardia, elevated blood pressure, and elation. b. nausea, vomiting, diaphoresis, anxiety, and hyperreflexia. c. mood lability, incoordination, fever, and drowsiness. d. excessive eating, constipation, and headache.

b. Nausea, vomiting, diaphoresis, anxiety, and hyperreflexia

A client diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should understand the need to deliver the care in what manner? a. maintaining a stern and authoritarian affect. b. providing care in a matter-of-fact manner. c. encouraging the client to express anger. d. being very rigid but not challenging.

b. Providing care in a matter-of-fact manner

Police bring a client to the emergency department after an automobile accident. The client demonstrates poor coordination and slurred speech, but the vital signs are normal. The blood alcohol level is 300 mg/dL (0.30 g/dL). Considering the relationship between the assessment findings and blood alcohol level, which conclusion is most probable? a. The client rarely drinks alcohol. b. The client has a high tolerance to alcohol. c. The client has been treated with disulfiram. d. The client has ingested both alcohol and sedative drugs recently.

b. The client has a high tolerance to alcohol

Consider this comment to three different nurses by a client diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be documented using which term? a. seductive. b. detached. c. manipulative. d. guilt-producing.

c. Manipulative

As a nurse prepares to administer medication to a client diagnosed with a borderline personality disorder, the client says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the client. Leave the medication on the table as requested. b. Respond to the client, "I'm worried that you might not take it. I'll come back later." c. Say to the client, "I must watch you take the medication. Please take it now." d. Ask the client, "Why don't you want to take your medication now?"

c. Say to the client, "I must watch you to take the medication. Please take it now."

Which behavior demonstrated by that a client diagnosed with an antisocial personality disorder most clearly warrants limit setting? a. Flattering the nurse b. Lying to other clients c. Verbal abuse of another client d. Detached superficiality during counseling

c. Verbal abuse of another client

A client diagnosed with major depressive disorder is receiving imipramine 200 mg 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

Which assessment findings are likely for an individual who recently injected heroin? a. Anxiety, restlessness, paranoid delusions b. Muscle aching, dilated pupils, tachycardia c. Heightened sexuality, insomnia, euphoria d. Drowsiness, constricted pupils, slurred speech

d. Drowsiness, constricted pupils, slurred speech

The history shows that a newly admitted client is impulsive. The nurse would expect the client to demonstrate what characteristic behavior? a. Adherence to a strict moral code. b. Manipulative, controlling strategies. c. Acting without thought on urges or desires. d. Postponing gratification to an appropriate time.

c. Acting without thought on urges or desires

One month ago, a client diagnosed with borderline personality disorder and a history of self-mutilation began dialectical behavior therapy. Today the client telephones to say, "I feel empty and want to hurt myself." The nurse should immediately take what action? a. Arrange for emergency inpatient hospitalization. b. Send the client to the crisis intervention unit for 8 to 12 hours. c. Assist the client to choose coping strategies for triggering situations. d. Advise the client to take an antianxiety medication to decrease the anxiety level.

c. Assist the client to choose coping strategies for triggering situations.

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior?a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

c. Avoidant

When counseling clients diagnosed with major depressive disorder, what therapy would an advanced practice nurse address the client's negative thought patterns? a. psychoanalytic b. desensitization c. cognitive-behavioral d. alternative and complementary

c. Cognitive-behavioral

The treatment team discusses the plan of care for a client diagnosed with schizophrenia and daily cannabis abuse who is having increased hallucinations and delusions. To plan effective treatment, the team should consider what intervention? a. provide long-term care for the client in a residential facility. b. withdraw the client from cannabis, then treat the schizophrenia. c. consider each diagnosis primary and provide simultaneous treatment. d. first treat the schizophrenia, then establish goals for substance abuse treatment.

c. Consider each diagnosis primary and provide simultaneous treatment

Which medication to maintain abstinence would most likely be prescribed for clients diagnosed with an addiction to either alcohol or opioids? a. Bromocriptine b. Methadone c. Disulfiram d. Naltrexone

d. Naltrexone

A client diagnosed with an antisocial personality disorder was treated several times for substance abuse, but each time the client relapsed. Which treatment approach is most appropriate? a. 1-week detoxification program b. Long-term outpatient therapy c. 12-step self-help program d. Residential program

d. Residential program

A client admitted yesterday for injuries sustained while intoxicated believes insects are crawling on the bed. The client is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis? a. Disturbed sensory perception b. Ineffective coping c. Ineffective denial d. Risk for injury

d. Risk for injury

A client admitted to an alcohol rehabilitation program tells the nurse, "I'm actually just a social drinker. I usually have a drink at lunch, two in the afternoon, wine with dinner, and a few drinks during the evening." The client is using which defense mechanism? a. Denial b. Projection c. Introjection d. Rationalization

a. Denial

What personality traits are most likely to be documented by a client demonstrating characteristics of an obsessive-compulsive personality disorder (OCPD)? a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

b. Perfectionist, inflexible

A nurse cares for a client experiencing an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurological d. Hepatic

b. Respiratory

A client diagnosed with major depressive disorder repeatedly tells staff, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. What is the priority nursing diagnosis? a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress

b. Risk for suicide

A nurse caring for a client diagnosed with major depressive disorder reads in the client's medical record, "This client shows vegetative signs of depression." Which nursing diagnoses most clearly relate to this documentation? (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, C, D, F

The nurse can assist a client to prevent substance abuse relapse by (Select all that apply.) a. rehearsing techniques to handle anticipated stressful situations. b. advising the client to accept residential treatment if relapse occurs. c. assisting the client to identify life skills needed for effective coping. d. advising isolating self from significant others until sobriety is established. e. informing the client of physical changes to expect as the body adapts to functioning without substances.

A, C, E

After discovering discrepancies and missing controlled substances, the nursing supervisor determines that a valued, experienced staff nurse is responsible. Which actions should the nursing supervisor take? (Select all that apply.) a. Refer the nurse to a peer assistance program. b. Confront the nurse in the presence of a witness. c. Immediately terminate the nurse's employment. d. Relieve the nurse of responsibilities for client care. e. Require the nurse to undergo immediate drug testing.

A, D

At a meeting for family members of alcoholics, a spouse says, "I did everything I could to help. I even requested sick leave when my partner was too drunk to go to work." The nurse assesses these comments as what? a. codependence. b. assertiveness. c. role reversal. d. homeostasis.

a. Codependence

A client diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this client? a. Tomato juice b. Orange juice c. Hot tea d. Milk

d. Milk

A client undergoing alcohol rehabilitation decides to begin disulfiram therapy. Client teaching should include the need to (Select all that apply.) a. avoid aged cheeses. b. avoid alcohol-based skin products. c. read labels of all liquid medications. d. wear sunscreen and avoid bright sunlight. e. maintain an adequate dietary intake of sodium. f. avoid breathing fumes of paints, stains, and stripping compounds.

B, C, F

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

B,D

A new client beginning an alcohol rehabilitation program says, "I'm just a social drinker. I usually have one drink at lunch, two in the afternoon, wine at dinner, and a few drinks during the evening." Which responses by the nurse will be most therapeutic? (Select all that apply.) a. "I see," and use interested silence. b. "I think you are drinking more than you report." c. "Social drinkers have one or two drinks, once or twice a week." d. "You describe drinking steadily throughout the day and evening." e. "Your comments show denial of the seriousness of your problem."

C, D

The admission note indicates a client 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, D, E

A client 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 client. Which communication technique will be effective? a. Make observations. b. Ask the client direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the client to reduce guilt feelings.

a. Make observations

What is the priority nursing intervention when caring for a client after an overdose of amphetamines? a. Monitor vital signs. b. Observe for depression. c. Awaken the client every 15 minutes. d. Use warmers to maintain body temperature.

a. Monitor vital signs.

A client is experiencing psychomotor agitation associated with major depressive disorder. Which observation presented by the client would the nurse associate with this symptom? a. pacing aimlessly around the room. b. asking the nurse to repeat instructions. c. reporting prickly skin sensations. d. demonstrating slowed verbal responses.

a. Pacing aimlessly around the room

What is the priority outcome for a client completing the fourth alcohol detoxification program in the past year? a. Prior to discharge, the client will state, "I know I need long-term treatment." b. Prior to discharge, the client will use denial and rationalization in healthy ways. c. Prior to discharge, the client will identify constructive outlets for expression of anger. d. Prior to discharge, the client will develop a trusting relationship with one staff member.

a. Prior to discharge, the client will state, "I know I need long-term treatment"

A client diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The client remains impulsive. Which nursing diagnosis is the initial focus of this client's care? a. Self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

a. Self-mutilation

Which features should be present in a therapeutic milieu for a client experiencing a hallucinogen overdose? a. Simple and safe b. Active and bright c. Stimulating and colorful d. Confrontational and challenging

a. Simple and safe

Which documentation for a client diagnosed with major depressive disorder indicates the treatment plan 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.

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

a. Social skills training

A nurse wants to research epidemiology, assessment techniques, and best practices regarding persons with addictions. Which resource will provide the most comprehensive information? a. Substance Abuse and Mental Health Services Administration (SAMHSA) b. Institute of Medicine (IOM)-National Research Council c. National Council of State Boards of Nursing (NCSBN) d. American Society of Addictions Medicine

a. Substance Abuse and Mental Health Services Administration (SAMHSA)

A client became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. a. The client will verbalize realistic positive characteristics about self by (date). b. The client will agree to take an antidepressant medication regularly by (date). c. The client will initiate social interaction with another person daily by (date). d. The client will identify two personal behaviors that alienate others by (date).

a. The client will verbalize realistic positive characteristics about self by (date).

What is the most challenging nursing intervention with clients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

b. Maintaining consistent limits

A hospitalized Client diagnosed with alcohol use disorder believes spiders are spinning entrapping webs in the room. The client is fearful, agitated, and diaphoretic. Which nursing intervention is indicated? a. Check the client every 15 minutes b. One-on-one supervision c. Keep the room dimly lit d. Force fluids

b. One-on-one supervision

A Client asks for information about alcoholics anonymous (AA). What is the nurse's best response? " a. AA is a form of group therapy led by a psychiatrist." b. AA is a self-help group for which the goal is sobriety." c. AA is a group that learns about drinking from a group leader." d. AA is a network that advocates strong punishment for drunk drivers."

b. AA is a self-help group for which the goal is sobriety.

During a psychiatric assessment, the nurse observes a client's facial expression is without emotion. The client says, "Life feels so hopeless to me. I've been feeling sad for several months." How will the nurse document the client's 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

Client diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA) help me?" What is the nurse's best response? a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

b. An individual is supported by peers while striving for abstinence one day at a time.

A client says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report using what medical term? a. dysthymia. b. anhedonia. c. euphoria. d. anergia.

b. Anhedonia

A nurse reviews vital signs for a client admitted with an injury sustained while intoxicated. The medical record shows these blood pressure and pulse readings at the times listed:0200: 118/78 mm Hg and 72 beats/minute0400: 126/80 mm Hg and 76 beats/minute 0600: 128/82 mm Hg and 72 beats/minute 0800: 132/88 mm Hg and 80 beats/minute 1000: 148/94 mm Hg and 96 beats/minute What is the nurse's priority action? a. Force fluids. b. Begin the detox protocol. c. Obtain a clean-catch urine sample. d. Place the Client in a vest-type restraint.

b. Begin the detox protocol

What is the priority intervention for a client diagnosed with major depressive disorder and feelings of worthlessness? a. distracting the client from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the client to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

b. Careful unobtrusive observation around the clock.

An adult in the emergency department states, "Everything I see appears to be waving. I am outside my body looking at myself. I think I'm losing my mind." When vital signs are slightly elevated what should the nurse suspect? a. a schizophrenic episode. b. hallucinogen ingestion. c. opium intoxication. d. cocaine overdose.

b. Hallucinogen ingestion

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

b. Hypertensive crisis

Transcranial Magnetic Stimulation (TCM) is scheduled for a client diagnosed with major depressive disorder. Which comment by the client indicates teaching about the procedure was effective? a. "They will put me to sleep during the procedure, so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

b. I might be a little dizzy or have a mild headache after each procedure.

A client says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your clients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

b. I understand that you have pain but giving medicine too soon would not be safe.

Which nursing diagnosis is appropriate to consider for a client diagnosed with any of the personality disorders? a. nonadherence. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

b. Impaired social interaction

A client diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." Which response by the nurse will best assist the client to reframe this overgeneralization? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

b. Let's look at one bad thing that happened to see if another explanation exists.

A hospitalized client diagnosed with alcohol use disorder believes the window blinds are snakes trying to get in the room. The client is anxious, agitated, and diaphoretic. The nurse can anticipate the health care provider will prescribe what medication intervention? a. narcotic analgesic, such as hydromorphone. b. sedative, such as lorazepam or chlordiazepoxide. c. antipsychotic, such as olanzapine or thioridazine. d. monoamine oxidase inhibitor antidepressant, such as phenelzine.

b. Sedative, such as lorazepam or chlordiazepoxide

A nurse set limits while interacting with a client demonstrating behaviors associated with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be documented using what term? a. denial. b. splitting. c. defensive. d. reaction formation.

b. Splitting

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the client to identify and test negative thoughts

b. Supporting physiological stability

In the emergency department, a client's vital signs are BP 66/40 mm Hg; pulse 140 beats/minute; respirations 8 breaths/minute and shallow. The nursing diagnosis is Ineffective breathing pattern related to depression of respiratory center secondary to opioid intoxication. What is the priority outcome? a. The client will demonstrate effective coping skills and identify community resources for treatment of substance abuse within 1 week of hospitalization. b. Within 4 hours, vital signs will stabilize, with BP above 90/60 mm Hg, pulse less than 100 beats/minute, and respirations at or above 12 breaths/minute. c. The client will correctly describe a plan for home care and achieving a drug-free state before release from the emergency department. d. Within 6 hours, the client's breath sounds will be clear bilaterally and throughout lung fields.

b. Within 4 hours, vitals signs will stabilize, with BP above 90/60 mmHg, pulse less than 100 bpm, and respirations at or above 12 breaths/minute.

A client diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the client is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this client? a. "You look nice this morning." b. "You're wearing a new shirt." c. "I like the shirt you are wearing." d. "You must be feeling better today."

b. You're wearing a new shirt.

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the client's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

c. Ability to provoke interpersonal conflict

A client diagnosed with major depressive disorder began taking escitalopram 5 days ago. The client now says, "This medicine isn't working." What is the nurse's best intervention? a. discuss with the health care provider the need to increase the dose. b. reassure the client that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the client for symptoms of improvement.

c. Explain the time lag before antidepressants relieve symptoms

When a client diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the client's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the client's behavior.

c. External controls are necessary due to failure of internal control.

Which statement made by a client diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

c. I felt empty and waned to hurt myself, so I called you.

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family? a. Need to restrict sodium intake to 1 gram daily. b. Need to minimize exposure to bright sunlight. c. Importance of reporting increased suicidal thoughts. d. Importance of maintaining a tyramine-free diet.

c. Importance of reporting increased suicidal thoughts

A nurse prepares for an initial interaction with a client with a long history of methamphetamine abuse. Which is the nurse's best first action? a. Perform a thorough assessment of the client. b. Verify that security services are immediately available. c. Self-assess personal attitude, values, and beliefs about this health problem. d. Obtain a face shield because oral hygiene is poor in methamphetamine abusers.

c. Self-assess personal attitude, values, and beliefs about this health problem.

Major depressive disorder resulted after a client's employment was terminated. The client now says to the nurse, "I'm not worth the time you spend with me. I am 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

A client has smoked two packs of cigarettes daily for many years. When the client tries to reduce smoking, anxiety, craving, poor concentration, and headache occur. This scenario should be described using which term? a. cross-tolerance. b. substance abuse. c. substance addiction. d. substance intoxication.

c. Substance addiction

A client being treated for depression has taken sertraline daily for a year. The client calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the client to: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

c. Take a dose of your antidepressant now and come to the clinic to see the health care provider.

A client diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the client says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will implement which intervention? a. limit the client's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the client strategies to manage postural hypotension. d. update the client's mental status examination.

c. Teach the client strategies to manage postural hypotension

A client diagnosed with major depressive disorder received six electroconvulsive therapy (ECT) sessions and aggressive doses of antidepressant medication. The client owns a small business and was counseled not to make major decisions for a month. What is the correct rationale for this counseling? a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with ECT. d. The client needs time to readjust to a pressured work schedule.

c. Temporary memory impairments and confusion may occur with ECT.

A client admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The client is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/minute. The client shouts, "Bugs are crawling on my bed. I've got to get out of here." What is the most accurate assessment of this situation? a. The client is attempting to obtain attention by manipulating staff. b. The client may have sustained a head injury before admission. c. The client has symptoms of alcohol withdrawal delirium. d. The client is having an acute psychosis.

c. The client has symptoms of alcohol withdrawal delirium.

What is an appropriate initial outcome for a client diagnosed with a personality disorder who frequently manipulates others? a. The client will identify when feeling angry. b. The client will use manipulation only to get legitimate needs met. c. The client will acknowledge manipulative behavior when it is called to his or her attention. d. The client will accept fulfillment of his or her requests within an hour rather than immediately.

c. The client will acknowledge manipulative behavior when it is called to his or her attention.

A new psychiatric technician says, "Schizophrenia ... schizotypal! What's the difference?" The nurse's response should include which information? a. A client diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the client remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality.

Which goal for treatment of alcohol use disorder should the nurse address first? a. Learn about addiction and recovery. b. Develop alternate coping strategies. c. Develop a peer support system. d. Achieve physiological stability.

d. Achieve physiological stability

A client is thin, tense, jittery, and has dilated pupils. The client says, "My heart is pounding in my chest. I need help." The client allows vital signs to be taken but then becomes suspicious and says, "You could be trying to kill me." The client refuses further examination. Abuse of which substance is most likely? a. phencyclidine (PCP) b. Heroin c. Barbiturates d. Amphetamines

d. Amphetamines

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning? The client a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

d. Confess with a pharmacist when selecting over the counter medications

A client diagnosed with borderline personality disorder (BPD) self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to which trigger? a. An inherited disorder that manifests itself as an incapacity to tolerate stress. b. Use of projective identification and splitting to bring anxiety to manageable levels. c. A constitutional inability to regulate affect, predisposing to psychic disorganization. d. Fear of abandonment associated with progress toward autonomy and independence.

d. Fear of abandonment associated with progress toward autonomy and independence

A disheveled client in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. What action will the nurse take? a. bring up the issue at the community meeting. b. calmly tell the client, "You must bathe daily." c. make observations about the client's poor personal hygiene. d. firmly and neutrally assist the client with showering.

d. Firmly and neutrally assist the client with showering.

When preparing to interview a client diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include which characteristics? a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

d. Grandiosity, self-importance, and a sense of entitlement

A client's spouse filed charges after repeatedly being battered. Which statement by this person supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

d. I hit because I am tired of being nagged. My spouse deserves the beating.

A client became severely depressed when the last of the family's six children moved out of the home 4 months ago. The client repeatedly says, "No one cares about me. I'm 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. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'd to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you."

d. I'd to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you.

A nurse worked with a client diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the client did not improve. The nurse is most at risk for what feelings? a. guilt and despair. b. over-involvement. c. interest and pleasure. d. ineffectiveness and frustration.

d. Ineffectiveness and frustration

A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money." These statements support what client characteristic? a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

d. Lack of guilt feelings

Family members of an individual undergoing a residential alcohol rehabilitation program ask, "How can we help?" What is the nurse's best response? a. "Alcoholism is a lifelong disease. Relapses are expected." b. "Use search and destroy tactics to keep the home alcohol free." c. "It's important that you visit your family member on a regular basis." d. "Make your loved one responsible for the consequences of behavior."

d. Make your loved one responsible for the consequences of behavior.

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include what characteristics? a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

d. Socially anxious, rambling stories, peculiar ideas

A client diagnosed with alcohol use disorder says, "Drinking helps me cope with being a single parent." Which therapeutic response by the nurse would help the client conceptualize the drinking objectively? a. "Sooner or later, alcohol will kill you. Then what will happen to your children?" b. "I hear a lot of defensiveness in your voice. Do you really believe this?" c. "If you were coping so well, why were you hospitalized again?" d. "Tell me what happened the last time you drank."

d. Tell me what happened the last time you drank

For which client behavior would limit setting be most essential? a. The client who clings to the nurse and asks for advice about inconsequential matters. b. The client who is flirtatious and provocative with staff members of the opposite sex. c. The client who is hypervigilant and refuses to attend unit activities. d. The client who urges a suspicious client to hit anyone who stares.

d. The client who urges a suspicious client to hit anyone who stares.

A nurse determines desired outcomes for a client diagnosed with schizotypal personality disorder. What is the best outcome? a. The client will adhere willingly to unit norms. b. The client will report decreased incidence of self-mutilative thoughts. c. The client will demonstrate fewer attempts at splitting or manipulating staff. d. The client will demonstrate ability to introduce self to a stranger in a social situation.

d. The client will demonstrate ability to introduce self to. a stranger in a social situation.