Mental Health test 4

Which documentation indicates that the treatment plan for a client experiencing 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 conversation D- Heavy makeup, seductive toward staff, pressured speech

A- Converses without interrupting, clothing matches, participates in activities

Which documentation indicated that the treatment plan for a client experiencing acute mania has been effective? A- Converses without interrupting, clotting matches, participates in activities B- Irritable, suggestible, distractible, napped for 10 minutes in afternoon C- Attention span short, writing copious notes, intrudes in conversation D- Heavy makeup, seductive toward staff, pressured speech

A- Converses without interrupting, clotting matches, participates in activities

A client diagnosed with major depressive disorder is taking a tricyclic antidepressant. 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 should: A- Explain how to manage postural hypotension and educate the client that side effects go away after several weeks. B- Tell the client that the side effects are a minor inconvenience compared with the feelings of depression. C- Withhold the drug, force oral fluids, and notify the HCP to examine the client. D- Teach the client how to use pursed-lip breathing.

A- Explain how to manage postural hypotension and educate the client that side effects go away after several weeks.

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 non judgement acceptance and support for the client. Select the nurse's most effective approach to communication. A- Make observations B- Ask the client direct questions C- Phrase question to require "yes" or "no" answers D- Frequent reassure the client to reduce guilt feelings

A- Make observations

A nurse is teaching a client about a tyramine-restricted diet. Which of the following meal choices selected by the client indicates that teaching is effective? 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

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 the intake of processed foods.

A- Offer laxatives, if needed B- Monitor food and fluid intake C- Provide a quiet sleep environment

What is the focus of priority nursing care for the period immediately after a client has electroconvulsive therapy (ECT) treatment? A- Supporting physiologic stability B- Reducing disorientation and confusion C- Monitoring pupillary responses D- Assisting the client to pay for the future

A- Supporting physiologic stability

A client diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The client owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for the 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 clients need's time to reorient him or herself to a pressured work schedule.

A- Temporary memory impairments and confusion can be associated with electroconvulsive therapy

A priority nursing intervention for a client diagnosed with major depressive disorder is: A- Distracting the client from self-absorption B- Carefully and inconspicuously observing the client around the clock C- Allowing the client to spend long periods alone in self-reflection D- Offering opportunities for the client to assume a leadership role in the therapeutic milieu

B- Carefully and inconspicuously observing the client around the clock

Which nursing diagnosis would most likely apply to both a client 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

A nurse is developing a plan of care for a client having a manic episode. Which nursing diagnoses are most likely? Select all that apply. A- Imbalanced nutrition, more that body requirements B- Disturbed thought processes C- Sleep deprivation D- Chronic confusion E- Social isolation

B- Disturbed thought processes C- Sleep deprivation

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

B- Hold a staff meeting to discuss consistency and limit setting approaches.

A client diagnosed with major depressive disorder tells the nurse, "Bad things that happen are always my fault." To assist the client 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- Let's 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- Let's look at one bad thing that happened to see if another explanation exists

A client diagnosed with bipolar disorder is in the maintenance phase of the treatment. The client asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's 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 clients 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

- A client experiencing acute mania is dancing atop the pool table in the recreation room. The client waves a cue in one hand and says, "I';; throw the pool balls if anyone comes near me." What should the nurse do first? A- Tell the client, "You need to be secluded B- Help the client down from the table C- Clear the room of all other clients D- Assemble a show of force

C- Clear the room of all other clients

A client 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

A nurse completes assessment on a client with a history of three suicide attempts. The client has been treated with fluoxetine for 2 weeks and now present with a bright affect, rates depressed mood at 1/10, and is much more communicative. Which nursing action is a priority? A- Advocate for the client to be discharged in the morning. B- Encourage the client to share mood improvement in group. C- Increase frequency of client observation. D- Request that the psychiatrist reevaluate the current medication list.

C- Increase frequency of client observation

During a collaborative team meeting the HCP considers adding an anticonvulsant drug to the list of medications for a client with a diagnosis of bipolar mood disorder. Which of the following drugs would the nurse anticipate the provider to prescribe for this client? A- Clonazepam B- Risperidone C- Lamotrigine D- Aripiprazole

C- Lamotrigine

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 judgement and hyperactivity D- Cognitive deficit and sad mood

C- Poor judgement and hyperactivity

Outcome identification for the treatment plan of a client with grandiose thinking associated with acute mania focuses on: A- Maintain 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

A client being treated for major depressive disorder has taken 300 mg amitriptyline daily for a year. The client 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 client: A- "Go to the nearest emergency department immediately." B- Do not be alarmed. Take tow aspirin and drink plenty of fluids C- Take one dose of the antidepressant. Come to the clinic to see the HCP 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 HCP

A Nurse provided medication education for a client who takes phenelzine for depression. Which behavior indicates that client education if effective? The client: 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 food with high selenium content, which should be avoided

C- consults the pharmacist when selecting over the counter medications

A client diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members ovserve increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is a priority nurse's intervention? A- Educate the client about the proper ways to perform personal hygiene and coordinate clothing B- Continue to monitor and document the client's speech patterns and motor activity C- Ask the HCP to prescribe an increased dose and frequency of lithium D- Consider the need to check the lithium levels. The client may not be swallowing medications

D- Consider the need to check the lithium levels. The client may not be swallowing medications

The nurse is teaching a client about ECT. Which of the following should the nurse include in the client's teaching? A- ECT is effective in the treatment of obsessive-compulsive disorders B- Medications will be administered to prevent seizure activity C- The greatest risk of ECT is brain damage and permanent memory loss. D- Temporary memory loss is the most common side effect

D- Temporary memory loss is the most common side effect

A client diagnosed with major depressive disorder is receiving imipramine 200 mg P.O every night at bedtime. Which assessment findings 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