Mental Health Unit Two
A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing response?
"A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis."
A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior?
"Agitated and pacing. Exhibiting grandiosity. Mood labile."
After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?
"Are you currently thinking about harming yourself?"
A client, who is taking transdermal selegiline (Emsam) for depressive symptoms, states, "My physician told me there was no need to worry about dietary restrictions." Which would be the most appropriate nursing response?
"Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended."
A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred?
"Between 50 and 80 percent of all people who kill themselves have a history of a previous attempt."
Hallucinations
are false sensory perceptions not associated with real external stimuli and may involve any of the five senses.
When planning care for a depressed client, which correctly written outcome should be a nurse's first priority?
The client will remain safe during hospital stay.
Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response?
"Focus on the feelings generated by the hallucinations and present reality."
After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn't seem as effective as before. Which question should the nurse ask to determine the cause of this problem?
"How many packs of cigarettes do you smoke daily?"
After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and done with these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care?
"How often is your spouse left alone?"
After a teenager reveals that he is gay, his father responds by beating him. The next morning, the teenager is found hanging in his closet. Which paternal grief responses should a nurse anticipate? Select all that apply.
"I can't believe this is happening." "If only I had been more understanding." "How dare he do this to me!"
A college student, who was nearly raped while jogging, completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met?
"I carry mace when I jog. It makes me feel safe and secure."
A client who has been newly diagnosed with depression is beginning tricyclic antidepressant therapy. The nurse has just completed teaching with this client. Which statement by the client indicates the need for further education?
"I do not need to quit smoking."
A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of "automatic thoughts." Which client statement is evidence of the "automatic thought" of discounting positives?
"I don't have a green thumb. Any old fool can grow a rose."
A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-lb. weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis?
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
A client is prescribed phenelzine (Nardil). Which of the following statements by the client should indicate to a nurse that the discharge teaching about this medication has been successful? (Select all that apply.)
"I'll have to let my surgeon know about this medication before I have my cholecystectomy." "I guess I will have to give up my glass of red wine with dinner." "I'll have to be very careful about reading food and medication labels." "I'll be sure not to stop this medication abruptly."
A nurse is working with a client who has just been prescribed buproprion (Wellbutrin). Which statement by the client indicates that further education is necessary?
"If I miss a dose, I will just take two pills the next day to catch up."
A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply?
"It sounds like you are feeling pretty hopeless."
The nurse educator is lecturing a group of nursing students on depression in adolescents. Which statement indicates that teaching has been effective?
"Many symptoms are attributed to normal adjustments of adolescents."
An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate?
"Rise slowly when you change position from lying to sitting or sitting to standing."
A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply?
"Suicide is a behavior."
A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information?
"Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area."
Which of the following nursing statements or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.)
"Tell me what happened." "What coping methods have you used, and did they work?" "Describe to me what your life was like before this happened."
A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response?
"The voices must sound scary, but the devil is not talking to you. This is part of your illness."
A despondent client who has recently lost her husband of 30 years tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing response is most appropriate?
"This may not be the best time for you to make such an important decision."
A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?
"Treatment is compromised when clients choose not to take their medications."
A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?
"Weight gain is a common, but troubling, side effect."
A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response?
"Your child has a chemical imbalance of the brain, which leads to altered perceptions."
A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse asks the nurse how Zyprexa works. Which is the appropriate nursing response?
"Zyprexa calms hyperactivity until the Eskalith takes effect."
A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include?
Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides.
A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? The following are the outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night.
3, 1, 4, 2
Crisis
A sudden event in one's life that disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem, can be defined as a
The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision?
Able to participate in a plan for safety; family agrees to constant observation
A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client's depressive symptoms?
According to learning theory, depression is a result of repeated failures.
Which nursing intervention strategy is most important to implement initially with a suicidal client?
Ask a direct question such as, "Do you ever think about killing yourself?"
A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first?
Assess suicide risk.
A client has been brought to the emergency department for signs and symptoms of chronic obstructive pulmonary disease (COPD). The client has a history of a suicide attempt 1 year ago. Which nursing intervention would take priority in this situation?
Assessing the client's pulse oximetry and vital signs
A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client's belief system, the nurse should conclude which client would potentially be at highest risk for suicide?
Atheist
Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.)
Avoid excessive use of beverages containing caffeine. Maintain a consistent sodium intake. Consume at least 2,500 to 3,000 mL of fluid per day.
The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide?
Be available to actively listen, support, and accept feelings.
Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder?
Being reliable, honest, and consistent during interactions
Which of the following rationales by a nurse explain to parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.)
Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. Children are naturally active, energetic, and spontaneous.
A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client's symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)?
Catatonic features may be associated with SIPD, whereas BPD has no catatonic features.
A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
Command hallucinations; warn the psychiatrist.
Which of the following are behavior assessment categories in the Broset Violence Checklist? (Select all that apply.)
Confusion Boisterousness Irritability
A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder?
Delusions of reference
What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode?
Depression can generate somatic symptoms that can mask actual physical disorders
Which client data indicates that a suicidal client is participating in a plan for safety?
Disclosing a plan for suicide to staff
A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate?
Discontinue the fluoxetine and rethink the client's diagnosis.
What is the best nursing rationale for holding a debriefing session with clients and staff after a take-down intervention has taken place in an inpatient unit?
Discuss the situation that led to inappropriate expressions of anger.
An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.)
Drastic temperature and barometric pressure changes A seasonal increase in social interactions Variations in serotonergic functioning
A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?
During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.
Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder?
Empowerment of the consumer
A nurse is planning care for a 13-year-old client who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents?
Escitalopram (Lexapro)
Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.)
Group therapy Medication management Supportive family therapy Social skills training
A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client?
Hamilton Depression Rating Scale
A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?
Placing the client on one-to-one observation while monitoring suicidal ideations
A nursing instructor is teaching about the Roberts' Seven-stage Crisis Intervention Model. Which nursing action should be identified with Stage IV?
Help the client deal with feelings and emotions.
During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time?
Hopelessness R/T altered mood AEB client statements
A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching?
How to make eye contact when communicating
The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.)
Hyperthyroidism Hypothyroidism Hyperadrenalism Hypoadrenalism
A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time?
Increase frequency of client observation.
Which of the following interventions should a nurse use when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.)
Maintain a calm demeanor. Clearly delineate the consequences of the behavior. Set limits on the behavior.
Order the following stages of Roberts' Seven-stage Crisis Intervention Model.
Psychosocial and lethality assessment. Rapidly establish rapport. Identify the major problems or crisis precipitants Deal with feelings and emotions Generate and explore alternatives. Implement an action plan Follow up
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?
Note escalating behaviors and intervene immediately.
A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide?
Observing the client at intervals determined by assessed data
Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client?
On his or her side, to prevent aspiration
A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia?
Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia.
A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time?
Placing the client on one-to-one observation while continuing to monitor suicidal ideations
A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action?
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide
The severity of depressive symptoms in the postpartum period varies from a feeling of the "blues," to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms?
Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)
A nurse admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge?
Provide a 3-day supply of Elavil with refills contingent on follow-up appointments.
A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lbs. by the end of the week?"
Provide client with high-calorie finger foods throughout the day.
Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder?
Provide personal space to respect the client's boundaries.
A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing?
Psychiatric emergency crisis
A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.)
Symptoms cause clinically significant impairment in important areas of functioning Depressive symptoms that do not meet the criteria for major depressive episode
A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
Restlessness and muscle rigidity
A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the priority nursing diagnosis for this client?
Risk for self-directed violence R/T hopelessness
A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize?
Risk for suicide R/T hopelessness
A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client?
Risk for violence: directed toward others
A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.)
Sad mood on most days Sad mood for the past 3 years after spouse's death
An older client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?
Serotonin syndrome; possibly caused by ingestion of two different SSRIs
A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?
Social isolation R/T poor self-esteem AEB secluding self in room
A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately?
Sore throat, fever, and malaise
A nursing instructor is teaching about the new DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD). Which of the following information should the instructor include? (Select all that apply.)
Symptoms include verbal rages or physical aggression toward people or property. Temper outbursts must be present in at least two settings (at home, at school, or with peers). DMDD is characterized by severe recurrent temper outbursts.
A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
Symptoms indicate lithium carbonate toxicity.
An inpatient client with a known history of violence suddenly begins to pace. Which additional client behavior should alert a nurse to escalating anger and aggression?
The client has a tense facial expression and body language.
A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis?
The client has experienced auditory hallucinations for the past 3 hours.
A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis?
The client has maxed-out charge cards and exhibits promiscuous behaviors.
Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self?
The client will express three positive self-attributes by day four.
During the planning of care for a suicidal client, which correctly written outcome should be a nurse's first priority?
The client will remain safe during the hospital stay.
A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What long-term outcome is realistic in addressing this client's crisis?
The client will return to previous adaptive levels of functioning by week six.
A client is newly admitted to an inpatient psychiatric unit. Which of the following is most critical to assess when determining risk for suicide?
The client's history of suicide attempts
A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client?
The more specific the plan is, the more likely the client will attempt suicide.
A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam?
To rule out neurocognitive disorder
A new mother is concerned about her ability to perform her parental role. She is quite anxious and ambivalent about leaving the postpartum unit. To offer effective client care, a nurse should be familiar with what information about this type of crisis?
This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis?
Thyroid-stimulating hormone (TSH) level of 25 U/mL
A nurse administers 100 percent oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?
To prevent anoxia resulting from medication-induced paralysis of respiratory muscles
A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe?
Valproic acid (Depakote)
An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?
With staff support and a show of solidarity, set firm limits on the behavior.
Schizoaffective
disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania).
Mania
is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.
Mood
pervasive and sustained emotion that may have a major influence on a person's perception of the world.