(N129) EAQ 2
A client is to begin lithium carbonate therapy. The nurse will ensure that the client has completed what baseline lab work before the drug's administration? 1. Renal studies 2. Cardiac enzyme studies 3. Adrenal function studies 4. Pulmonary function studies
1 Rationale: Because of the severity of side effects and the stress lithium places on the renal and cardiovascular systems, its administration is contraindicated in clients with renal or cardiovascular disease. Baseline renal studies can be used for comparison in the future. Baseline cardiac enzymes are not necessary prior to initiation of lithium therapy; they are drawn when damage to the heart is suspected. Adrenal function studies are not necessary; lithium does not alter adrenal gland functions. Pulmonary function studies are not necessary; lithium does not cause alterations in pulmonary function.
The nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best nursing approach? 1. Discussing topics other than the paralysis 2. Explaining the reason for the physical problem 3. Asking how the client feels about being paralyzed 4. Encouraging the client to slowly walk around the room
1 Rationale: Discussion of signs and symptoms should not be initiated by the nurse; the signs and symptoms should be accepted by the nurse. Discussion should be focused on the client's feelings and current situation. Explaining the reason for the physical problem may take away the client's unconscious defense and increase anxiety. Asking how the client feels about being paralyzed focuses on the paralysis rather than feelings. Encouraging the client to slowly walk around the room denies the client's symptoms; in reality this client cannot make the legs move to walk.
An inexperienced nurse assigned to a mental health daycare setting elects to begin a one-on-one therapeutic relationship with a depressed, withdrawn older client. What fear is most likely the basis for the nurse's selection of this client? 1. Saying the wrong thing to a more alert client 2. Experiencing rejection by a middle-aged client 3. Feeling too concerned about the well-being of a younger client 4. Being ignored when trying to work with a client of the opposite sex
1. Rationale: The greatest fear of an inexperienced nurse is saying the wrong thing and doing harm to a client; it is important to recognize that it actually can become a therapeutic encounter whereby both the client and the nurse can learn from the situation. Rejection may occur with any client; fear of rejection usually is not an overwhelming concern of nurses. Usually feeling too concerned about a younger client is not an overwhelming concern of nurses. The sex of the client does not dictate whether the nurse will be ignored or accepted.
A depressed client has been prescribed a tricyclic antidepressant. How long does the nurse inform the client that it usually takes before clients notices a significant change in the depression? 1. 4 to 6 days 2. 2 to 4 weeks 3. 5 to 6 weeks 4.. 12 to 16 hours
2 Rationale: It takes 2 to 4 weeks for the tricyclic antidepressant to reach a therapeutic blood level. Time spans of 4 to 6 days and 12 to 16 hours are both too short for a therapeutic blood level of the drug to be achieved. Improvement in depression should be demonstrated sooner than 5 to 6 weeks.
A nurse is assessing several depressed clients. Which behavior should alert the nurse to closely monitor a client for a suicide attempt? 1. When the client does not eat 2. If the client describes a plan for suicide 3. If the client cannot list any future goals 4. When the client's depression appears to deepen
2 Rationale: The development of a plan means that the client has moved past the questioning phase and into the acting-out phase of suicide. The client may stop eating if the depression is deepening; this may signal a decrease in motivation and a decrease in suicide potential. The client may not have any identifiable goals and still want to live. The client's depression appearing to deepen is not a gauge of the potential for suicide by itself; more information is required.
A client in a mental health facility with the diagnosis of bipolar disorder, manic phase, is argumentative, domineering, and exhibitionistic. A visitor reports that this client is running down the hall, scaring people. What should the nurse do first? 1. Ask the client the reason for running down the hall. 2. Assess the client's behavior in a nonthreatening manner. 3. Gather several staff members to approach the client together. 4. Contact the primary healthcare provider for seclusion and medication instructions.
2 Rationale: The nurse needs to make an assessment; the nurse cannot rely on a visitor's observations. The client will probably be unable to explain the actions. Intervening without first assessing the client may be perceived as threatening if the client is not out of control. The provider may be contacted later, after the client has been assessed.
One morning a client with the diagnosis of acute depression says, "God is punishing me for my past sins." What is the best response by the nurse? 1. "Why do you think that?" 2. "You sound very upset about this." 3. "Do you believe that God is punishing you for your sins?" 4. "If you feel this way, you should talk to your spiritual advisor."
2 Rationale: The response focuses on the client's feelings rather than the statement, and it serves to open channels of communication. "Why do you think that?" asks the client to decide what is causing the feelings; most people are unable to explain why they feel as they do. "Do you believe that God is punishing you for your sins?" simply echoes the client's statement and does not reflect feelings or stimulate further communication. "If you feel this way, you should talk to your spiritual advisor" does nothing to stimulate further communication; in fact, it tells the client to talk about the feelings with someone else.
A nurse is performing a mental status assessment. What is being assessed when the nurse notes that the client is cooperative? 1. Mood 2. Affect 3. Attitude 4. Perception
3 Rationale: Attitude relates to the approach or manner of the client during the interaction with the interviewer (e.g., cooperative, resistive, friendly, ingratiating). Mood is a feeling state reported by the client (e.g., sad, depressed, angry, anxious, happy). Affect is a person's mood, feelings, or tone, observable as an outward manifestation; it may be referred to as inappropriate, flat, or blunted. Perception is how a person views and interprets a situation; a perception may or may not be based in reality.
A client is admitted to the hospital with a diagnosis of depression. What clinical manifestations of depression does the nurse expect when assessing this client? 1. Flight of ideas 2. Suspicion of others 3. Psychomotor retardation 4. Intrusive social behaviors
3 Rationale: Both thought and motor activity, which require physical and psychic energy, are commonly slowed when someone is depressed. Flight of ideas is associated with manic behavior because it requires psychic energy. Suspicion is associated with paranoid ideation and is less common with depression. Intrusive social behaviors are associated with manic behavior.
A client has a diagnosis of schizoid personality disorder. During the assessment what should the nurse expect of the client's behavior? 1. Rigid and controlling 2. Dependent and submissive 3. Detached and socially distant 4. Superstitious and socially anxious
3 Rationale: Clients with the diagnosis of schizoid personality disorder neither desire nor enjoy close relationships; prefer solitary activities; and demonstrate emotional coldness, detachment, and a flattened affect. Rigid and controlling behavior is typical of clients with the diagnosis of obsessive-compulsive personality disorder. Dependent and submissive behavior is typical of clients with the diagnosis of dependent personality disorder. Superstitious and socially anxious behavior is typical of clients with the diagnosis of schizotypal personality disorder.
A 2-year-old boy's mother attempts suicide and is admitted to a mental health facility. What is the nurse's priority when planning care for this client? 1. Supporting parental skills 2. Ensuring the child's safety 3. Maintaining constant observation of the client 4. Encouraging the client's participation in activities
3 Rationale: The client must be observed closely, because this suicide attempt increases the probability of another attempt. Supporting parental skills is important for therapy, but prevention of suicide takes precedence. Ascertaining the child's safety is important but not the priority for the nurse caring for the suicidal client. Although participation in activities is important for therapy, prevention of suicide takes precedence.
In what situation should a nurse anticipate that a client will experience a phobic reaction? 1. When seeking attention from others 2. When thinking about the feared object 3. When coming into contact with the feared object 4. When being exposed to an unfamiliar environment
3 Rationale: With phobias, the individual transfers anxiety to a safer inanimate object or situation. Therefore the anxiety and resulting feelings will be precipitated only when the client is in direct contact with the object or situation. Phobias are severe anxiety reactions, not attention-seeking actions. It is not thinking about the feared object that causes anxiety; it is the possibility of having to come into contact with it. It is the presence of the phobic object or situation that triggers the anxiety, not the unfamiliarity of the environment.
A 7-year-old is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears the child crying when alone. What basis for these behaviors should the nurse consider? 1. The child feels different from classmates. 2. The child will be happier living with the father. 3. The child is working through feelings of shame. 4. The child may be experiencing self-blame for the parents' breakup.
4 Rationale: Children usually blame themselves for their parents' marital problems, believing that they are the reason that a parent leaves. No data are presented to indicate that the child feels different from peers, that the child will be happier living with the father, or that the child is working through feelings of shame.
A woman with bipolar disorder, manic episode, has been spending thousands of dollars on clothing and makeup. She has been partying in bars every night and rarely sleeps or eats. The nurse in the outpatient clinic knows that this client rarely eats. What does the nurse recognize as the most likely cause of her eating problems? 1. Feelings of guilt 2. Need to control others 3. Desire for punishment 4. Excessive physical activity
4 Rationale: During a manic episode hyperactivity and the inability to sit still long enough to eat are the causes of eating difficulties. Feelings of guilt do not precipitate eating difficulties in clients with the diagnosis of bipolar disorder, manic episode. Clients in a manic episode of bipolar disorder have a need to avoid and therefore control anxiety associated with depression; they do not have a need to control others; nor do they have a desire for punishment.
As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join and says, "I have nothing to talk about." What is the best response by the nurse? 1. "Maybe tomorrow you'll feel more like talking." 2. "Could you start off by talking about your family?" 3. "A person like you has a great deal to offer the group." 4. "You feel you won't be accepted unless you have something to say?"
4 Rationale: The statement about the client's feelings of acceptance is a reflective statement that allows the client to either validate the statement or correct the nurse. Postponing the conversation delays addressing the problem and avoids exploring feelings. Asking the client to start talking about her or his family is a response that gives advice and does not allow the client to explore feelings. Stating that the client has a lot to offer the group denies the client's statement and does not allow the exploration of feelings.
