psych NCLEX

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on:

*1. Weight loss* 2. Sleep patterns 3. Medication compliance 4. Onset of the crying spells *rationale* All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." *4. "You sound very upset. Are you thinking of hurting yourself?"* *rationale* Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Options 1, 2, and 3 are not therapeutic responses.

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response?

1. "It sounds as though you need to speak to the psychiatrist." 2. "Perhaps you'd like to see the ECT room and speak to the staff." 3. "Your child has decided to have this treatment. You should be supportive of the decision." *4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"* *rationale* The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.

A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client?

1. A puzzle *2. Drawing* 3. Checkers 4. Paint by number *rationale* Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by:

1. Poor dietary choices 2. Lack of exercise and poor diet 3. Inadequate dietary intake and dehydration *4. Psychomotor retardation and side effects of medication* *rationale* Constipation can be related to inadequate food intake, lack of exercise, and poor diet. In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention.

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:

*1. Feed, bathe, and dress the client as needed until the client can perform these activities independently.* 2. Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living. 4. Have the client's peers confront the client about how the noncompliance in addressing activities of daily living affects the milieu. *rationale* The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options 2 and 3 are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option 4 will increase the client's feelings of poor self-esteem and unworthiness.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?

*1. One-to-one suicide precautions* 2. Suicide precautions, with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client report suicidal thoughts immediately *rationale* One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 are not appropriate, considering the situation. Option 4 may be an appropriate nursing intervention, but the priority is stated in option 1. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

1. "My medications won't make me anxious." 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well." *4. "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."* *rationale* There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.