Mood, Adjustment, and Dementia Disorders

The nurse is comforting the family member of a client that just died. The family member states, "There has to be a mistake. We just spent a week on vacation together and all was fine." What is the best response by the nurse?

"It is common to feel denial when a family member has died unexpectedly."

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on time spent in bed during the day.

The parents of a child with attention deficit hyperactivity disorder (ADHD) say they are concerned because the child is losing weight. Which suggestion can the nurse give to the parents regarding the weight loss?

have high-calorie finger foods available for the child to eat

A family of a client with paranoid personality disorder is trying to understand the client's behavior. Which intervention would help the family?

help the family manage the client's eccentric actions

A client with antisocial personality is admitted to a psychiatric facility. Which nursing interventions would be most effective for handling this client's inappropriate behavior? Select all that apply.

identifying limits establishing consequences for violations

The nurse finds a client with Alzheimer's disease wandering in the hall at 3 a.m. The client has removed all clothing and says to the nurse, "I'm just taking a stroll through the park." What is the priority action by the nurse?

immediately help the client back to his or her room and into some clothing

A client is diagnosed with dependent personality disorder. When gather data from the client, which behavior would the nurse suspect as being most likely indicative of ineffective coping?

inability to make choices and decisions without advice

A client has depression after the death of a child. After a suicide attempt, the client is admitted to the inpatient psychiatric unit. During the admission interview, the client reports no longer wanting to die. Which action would be most appropriate for the nurse?

inspect the client's personal belongings for potentially dangerous objects

A home health care nurse is working with the family of a client who has Alzheimer's disease. The client's spouse is too exhausted to continue providing care alone and the client's adult children live too far away to provide relief on a weekly basis. Which nursing intervention would be most helpful?

investigate community resources for adult day care and other services

A nurse is providing care to a client diagnosed with bipolar disorder, currently experiencing mania. When reviewing the plan of care for the client, which intervention would the nurse most likely implement at this time?

listening attentively with a neutral attitude, avoiding situations involving increased stimulation

A nurse is assisting with the education for the family of a client with dementia. Which response by the nurse would be the most accurate definition of dementia?

loss of intellectual abilities that impairs the ability to perform basic care

A family member brings a client to the emergency department that has allegedly taken approximately 20 pills from a bottle of narcotics. The nurse obtains a blood pressure of 90/56 mm Hg, heart rate of 46, and a respiratory rate of 10 breaths/minute. What is the priority nursing intervention?

maintain a patent airway

The nurse is assisting with the admission of a client with an amnesic disorder. Which laboratory evaluation should the nurse prepare a client this client that assist with the cause of the disorder?

metabolic and endocrine tests

Which nursing intervention would help a client diagnosed with Alzheimer's disease (AD) perform activities of daily living?

provide ample time for the client to complete basic tasks

A client taking metronidazole asks the nurse if it is okay to drink alcohol while taking this medication. What is the nurse's best response?

"Abstain from alcohol while on the drug."

During a routine physical exam the client reports concerns about getting older and losing cognitive abilities. Which response by the nurse is most appropriate?

"Aging does increase the risk for these changes in ability but they are not an absolute."

A client is admitted to the behavioral health unit with severe depression. The nurse suspects that the client is at risk for suicide. Which question would be most appropriate for the nurse to ask while collecting data about the risk for suicide?

"Are you having thoughts about hurting yourself?"

A hospitalized client who cares for a parent with Alzheimer's disease at home reports feeling guilty because, at times, the client wishes the parent would die. When talking with the client, which response would be most appropriate?

"Being responsible for your father's care must be difficult."

A nurse is caring for a client who states, "I can't keep living like this. I just want to end it all." What is the nurse's best response?

"Do you plan to harm yourself?"

The nurse is obtaining data about the early life of a client with borderline personality disorder (BPD). Which statement made by the client would correlate with this diagnosis?

"I had a violent, chaotic family life."

The daughter of a client diagnosed with Alzheimer's disease tells a nurse, "My mother is incompetent. You'll need to contact me or my sister if any decision must be made about my mother's care." Which response by the nurse is best?

"I must respect your mother's rights until she is legally deemed incompetent."

A nurse isobserving the effectiveness of an assertiveness group attended by a client with dependent personality disorder. Which client statement indicates the group had therapeutic value?

"I want to talk about something that's bothering me."

A client has been recently started on phenelzine, a monoamine oxidase (MAO) inhibitor. Which statements indicate that the client requires further educational reinforcement about this type of drug? Select all that apply.

"If I have any insomnia I will drink warm milk." "My family will just have to put up with any new irritability"

Rivastigmine has been prescribed to a client. When reviewing home administration with the client and spouse, which response indicates the need for further instruction?

"If I miss a dose by more than an hour I should wait until the next day to take it."

A client who has been taking imipramine, 125 mg P.O. daily, for 1 week wants to stop taking the medication because the client still feels depressed. Which response by the nurse would be most appropriate at this time?

"Imipramine must build up to a therapeutic level; it may take 3 to 4 weeks to reduce depression."

An adolescent client is diagnosed with attention deficit hyperactivity disorder (ADHD). What statement made by the client demonstrates an understanding of the disorder?

"It increases sensitivity to the environment and surroundings."

A client avoids leaving home to shop for groceries and states to the nurse, "I feel crazy from the fear even when I know it is unrealistic." What is the best response by the nurse?

"It is better if you gradually face your fear with professional coaching."

A client with antisocial personality disorder says, "I always want to blow things off." Which response by the nurse is most appropriate?

"Let's work on considering some options and strategies."

A client who lost her spouse suddenly 30 years ago tells a nurse during an interview, "My husband's shoes are at the side of the bed where he left them." The client's daughter informs the nurse that her mother constantly speaks about her deceased husband. Which statement by the daughter shows an understanding of maladaptive grief?

"My mother is in a prolonged phase of the grief process."

The nurse is discussing the incidence of obsessive-compulsive disorder (OCD) with a client. Which statement made by the client demonstrates an understanding of the education?

"OCD is as common as diabetes and asthma."

Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective?

"Sometimes I can see what causes relationship problems."

The spouse of a client diagnosed with vascular dementia asks the nurse if this is the same as having Alzheimer's disease (AD). Which response by the nurse is most appropriate?

"There are similarities in the conditions but they are not the same condition."

On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response?

"To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here."

A client diagnosed with Alzheimer's disease (AD) tells the nurse that today a visitor is coming to have lunch. The nurse knows that the visitor isn't coming that day. Which response by the nurse would be most appropriate for this situation?

"Today is Monday, March 8, and we'll be eating lunch in the dining room."

An older adult client is prescribed fluoxetine, 40 mg by mouth twice per day, for treatment of depression. The client has difficulty swallowing, so the pharmacy dispenses the oral solution containing 20 mg/5 mL. How many milliliters of solution should the nurse administer to achieve the prescribed dose? Record your answer using a whole number.

10

The client is prescribed alprazolam 0.5 mg orally three times a day for panic disorder. The nurse has 0.25 mg tablets available. How many tablets will the nurse administer per dose? Record your answer using a whole number.

2

The nurse is caring for a client who has been diagnosed with delirium. Which of the following is characteristic of delirium?

Acute onset and lasts hours to a number of days

A nurse is caring for an older adult client who exhibits signs of dementia. When assisting with the development of the client's plan of care, the nurse incorporates understanding that which condition is the most common cause of dementia?

Alzheimer's disease

A client with gradually occurring global impairments of cognitive functioning, memory, and personality is most likely to have:

Alzheimer's-type dementia.

Which foods are contraindicated for a client taking tranylcypromine?

Chicken livers, Chianti wine, and beer

A client with self-inflected wrist lacerations was stabilized in the emergency department and then transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. After initiating antidepressant therapy, the client is now exhibiting an increase in energy levels. What nursing intervention is most appropriate?

Continue suicide precautions.

The nurse is assigned to a client who, after a medication teaching session with the nurse, began receiving amitriptyline 1 week ago to treat depression. The client now refuses to take the medication, stating that it has caused blurred vision, dry mouth, and constipation but hasn't improved the mood. Which nursing diagnosis is most appropriate for this client?

Deficient knowledge related to inadequate understanding of teaching

Discharge instructions for clients receiving tricyclic antidepressants include which of following information?

Don't consume alcohol.

A mother of three small children is admitted to the psychiatric unit with severe depression. She tells a nurse that she has no reason to live and would "be better off dead." Which intervention by the nurse would best support the client at this time?

Encourage the client to express her feelings.

A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would best prevent further regression in the client's personal hygiene?

Encouraging the client to perform as much self-care as possible

A client who was attempting to carry out a suicide plan is admitted to the unit. Which nursing intervention is the highest priority for this client?

Making sure that a health care team member stays with the client

Which nursing action is most appropriate when trying to diffuse a client's impending violent behavior?

Helping the client identify and express feelings of anxiety and anger

A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which early adverse effect of lithium?

Polyuria

The nurse is gathering data from a client suspected of early dementia. Which finding shows impairment in abstract thinking and reasoning?

The client can't find similarities and differences between related words or objects.

The nurse is preparing a teaching plan for an elderly client with depression who will continue on a prescription for venlafaxine after discharge. Because of age-related cognitive changes the nurse should use which approach to client teaching?

Repeat new information frequently.

A nurse is assigned to care for a client recently admitted to the psychiatric facility who has attempted suicide. When collecting data from the client, which action would be most appropriate at this time?

Search the client's belongings carefully for items that could be used to attempt suicide.

A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client?

Set limits, with clear and consistent consequences, for behavior.

A 40-year-old executive who was unexpectedly laid off from work 2 days ago reports fatigue and an inability to cope. He admits drinking excessively over the last 48 hours. This behavior is an example of which condition?

Situational crisis

A client has been prescribed venlafaxine extended-release capsules by mouth, once daily, for major depression following a stroke. The client has difficulty swallowing pills since the stroke. How should the nurse intervene?

Sprinkle the contents of the capsule over applesauce and administer it to the client.

While the nurse is collecting data on a client with depressive symptoms, the client reports taking an herbal medication to help with symptoms. When the nurse questions the client further, which herbal therapy would the client most likely report using?

St. John's wort

A family member is caring for a client diagnosed with Alzheimer's disease. The nurse is gathering data about the client and family. Which situation would the nurse identify as most likely to cause the caregiver depression and role strain?

The caregiver feels unable to control the client's behavior and the caregiving situation.

Which long-term goal is appropriate for a client with paranoid personality disorder who is trying to improve peer relationships?

The client will become involved in activities that foster social relationships.

The health care provider has prescribed methylphenidate. Which findings in the client's medical history would warrant concern about this therapy? Select all that apply.

The client's history indicates a recent myocardial infarction. The client has a history of alcoholism.

The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which trait would the nurse be likely to uncover during data collection?

a low tolerance for frustration

A client arrives at a mental health clinic stating, "I feel numb and empty most of the time. I don't have any energy to do what I normally do." Further investigation reveals that the client has experienced these difficulties since the death of a best friend 6 months ago. Which response by the nurse would be best?

advise the client that it is not unusual for grieving and loss to continue for quite some time

The nurse observes a child with autism banging his or her head against the floor repetitively. Which nursing action is the priority?

apply a helmet on the child

A client who has just had electroconvulsive therapy (ECT) asks for a drink of water. Which intervention would be the nurse's priority?

assess the gag reflex

The nurse is caring for a client who has been diagnosed with narcolepsy. Which actions may assist the client in managing this condition? Select all that apply.

avoid smoking limit caffeine intake follow a regular schedule for sleep and rest

The nurse is caring for a client who reports feeling very "stressed out today." When collecting data from this client, which physical characteristics would the nurse expect to observe related to the alarm stage of stress? Select all that apply.

pupil dilation hypertension

The nurse is assisting with the development of a treatment plan for a client with a specific phobia. Which intervention should the nurse prepare the client for?

behavioral therapy

Which intervention can the nurse discuss with the parents of a child with attention deficit hyperactivity disorder (ADHD) to help their child to achieve daily tasks?

break up the task into smaller steps

A client with major depression hasn't responded to antidepressants. Which intervention should the nurse prepare the client for?

electroconvulsive therapy (ECT)

A client exhibits signs of dementia. Which condition, that can cause a dementia similar to Alzheimer's disease (AD), is reversible?

electrolyte imbalance

A licensed practical nurse is reinforcing instructions with a new group of mental health aides about setting limits for clients' inappropriate or unacceptable behavior. The nurse informs them that this action would be most important for which client?

client experiencing mania

The nurse is obtaining data from a group of clients with depression. Which clients would the nurse recognize would most benefit from electroconvulsive therapy (ECT)?

clients who are severely depressed and do not respond to medication trials

The nurse is providing care to a client with Alzheimer's disease (AD). Which nursing intervention takes priority?

control the environment by providing structure, boundaries, and safety

A client with a diagnosis of borderline personality disorder is admitted to the unit after slashing their wrist. When assisting with the planning of care, which goal is most appropriate for this client?

establish a therapeutic relationship with the client

The nurse is caring for a client with a cognitive disorder. Which characteristic does the nurse observe that correlates with a cognitive disorder?

deficit in memory

The nurse is collecting data for a client diagnosed with a dementia disorder. Which factor is most important for the nurse to determine when collecting data for this diagnosis?

degree of impairment

A client with bipolar disorder is having difficulty sleeping. Which behavior modification technique should the nurse reinforce with the client?

develop a sleep ritual

Which short-term goal is appropriate for a client with borderline personality disorder who displays low self-esteem?

express fears and feelings

Family members of a client with bipolar disorder tell the nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

flight of ideas and inflated self-esteem.

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to:

fold towels and pillowcases.

A client with depression doesn't respond to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). The nurse knows that most people respond negatively to the thought of an electric current passing through the brain. Therefore, when discussing ECT with the client, the nurse should:

refer to the procedure as a "treatment" instead of "shock therapy."

A nurse is caring for a client with paranoid personality disorder. What behaviors does the nurse anticipate observing?

secretiveness

A client with a narcissistic personality disorder states to the nurse, "I don't care what you say. I know much more about nursing than you ever will!" What nursing intervention is essential at this time?

set limits for socially acceptable client behavior

A confused client is brought to the emergency room. The client's has a heart rate of 108/minute and blood pressure 102/68 mm Hg. The family states the client has been taking lithium for manic episodes. Which laboratory results would be most concerning to the nurse?

sodium 150 mEq/L (150 mmol/L), hemoglobin 19.2 g/dL (192 g/L), blood urea nitrogen (BUN) 38 mg/dL (13.57 mmol/L)

A client with paranoid personality disorder is discussing current problems with a nurse. Which nursing intervention has priority in the care plan?

suggest the client clarify thoughts and beliefs about an event

A client taking antidepressants for major depression for about 3 weeks now states " I'm feeling better." Which complication should the client be monitored for?

suicidal ideation

When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that:

the client has undergone a thorough medical evaluation.

The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client?

use short, simple commands when providing instruction

The nurse is assisting with a care plan for a client admitted with Alzheimer's dementia. The family reports that the client has to be watched closely for wandering behavior at night. Which nursing action will be of the greatest importance?

using a bed check monitor device