Mental Health
A client who has a diagnosis of depression is attending group therapy. During the group meeting, the nurse asks each member to identify one goal for the day. When it is the client's turn, they do not respond. Which of the following actions should the nurse take before repeating the request to the client? (A) Allow the client time to formulate an answer. (B) Prompt the client to give a response. (C) Move on to the next client. (D) Offer the client a suggestion for a goal.
Allow the client time to formulate an answer. [Slowed response time is common in clients who have depression] ("Offer the client a suggestion for a goal." A client who has depression is able to make decisions as necessary. Therefore, the nurse should not deny the client this ability to participate in the group therapy)
A nurse in the emergency department is caring for a client who has alcohol toxicity and is unresponsive. Which of the following interventions should the nurse take? (A) Gather supplies for endotracheal intubation. (B) Administer a beta blocker intravenously. (C) Position the client in a low-Fowler's position. (D) Place a cooling blanket over the client.
Gather supplies for endotracheal intubation. [expected finding of an unresponsive client who has alcohol toxicity is respiratory depression] (Hypotension is an expected finding in a client who has alcohol toxicity. Therefore, it is not an appropriate nursing action to administer medications that will lower the client's blood pressure) (Aspiration of emesis is a potential risk for a client. The nurse should implement measures to reduce the risk of aspiration of emesis for a client who has alcohol poisoning. Low-Fowler's position can increase the client's risk for aspiration) (The nurse should expect the client who has alcohol toxicity to have cool skin. Therefore, the nurse should place a warming blanket over the client)
A nurse is planning care for a client who has schizophrenia and reports auditory hallucinations. Which of the following interventions should the nurse include in the plan? (A) Promote the use of music to compete with the client's auditory hallucinations. (B) Inform the client that the auditory hallucinations are not real. (C) Avoid asking the client if they are experiencing auditory hallucinations. (D) Instruct the client on the use of voice recognition regarding the auditory hallucinations.
Promote the use of music to compete with the client's auditory hallucinations. [Competing reality-based stimulation such as the use of music or television during auditory hallucinations can assist in limiting the effect the hallucinations have on the client's stress level] (Informing a client that auditory hallucinations are not real will increase the client's anxiety level. The nurse should acknowledge that the client is hearing auditory hallucinations, but should tell the client that they do not hear anything to reinforce reality) (The nurse should ask the client if they are hearing voices to evaluate whether these are command hallucinations, which can place the client or others at risk for harm) (The nurse should assist the client to develop the skill of voice dismissal when auditory hallucinations occur. This involves commanding the voices to stop, which gives the client a sense of control)
A nurse is discussing the home care of a client who has advanced Alzheimer's disease with the client's partner, who is planning to go out of town for several days. Which of the following resources should the nurse recommend to the caregiver? (A) Respite care (B) Partial hospitalization (C) Adult day care program (D) Geropsychiatric unit
Respite care [Respite care programs allow the client to stay in a nursing facility for a set number of days, allowing the caregivers to go on vacation or have some time to themselves] (Partial hospitalization provides services for several hours during the day, but they are not designed to offer 24-hr care) (Adult day care programs provide services throughout the day to clients who have Alzheimer's disease, allowing the caregiver the ability to work or have a break. The clients return home in the evening. A client who has advanced Alzheimer's disease is unable to safely remain at home unattended) (A geropsychiatric unit provides care for clients requiring acute psychiatric services due to sudden mental status changes, psychosis, or other mental health issues. These services are ideal for clients who are at risk of harming themselves or others)
A community health nurse is planning an education program about depressive disorders. Which of the following factors should the nurse include as increasing the risk for depression? (A) Male gender (B) Hyperthyroidism (C) Substance use disorder (D) Being married
Substance use disorder (The nurse should identify that female clients are at an increased risk for the development of depressive disorders) (hypothyroidism pts are at an increased risk for the development of depressive disorders) (clients who are single are at an increased risk for the development of depressive disorders)
A nurse is reviewing the medical record of a client who has anorexia nervosa. Which of the following findings should the nurse identify as an indication the client requires hospitalization? (A) Total body fat 8.7% (B) Potassium 3.6 mEq/L (C) Temperature 36.1° C (96.9° F) (D) Heart rate 54/min
Total body fat 8.7% [The nurse should recognize that criteria for hospitalization includes having a weight less than 75% of ideal body weight, or less than 10% body fat. The nurse should report this finding to the provider] (Criteria for hospitalization include a temperature less than 36° C {96.8° F}) (Criteria for hospitalization is a heart rate less than 50/min during the daytime)
A nurse is documenting admission assessment findings for a client who has major depressive disorder. The nurse should identify which of the following findings as clinical manifestations? (Select all that apply.) [ ] Feelings of hopelessness [ ] Pressured speech [ ] Grandiosity [ ] Anhedonia [ ] Flat facial expression
[ ] Feelings of hopelessness [ ] Anhedonia - reduced ability to experience pleasure [ ] Flat facial expression - no facial expressions