Psycho - Unit 3

Interpersonal therapy

-treatment that strengthens social skills and targets interpersonal problems, conflicts, and life transitions -focuses on communication patterns & the way the patient relates to others -grief issues

A nurse is reinforcing teaching with a client about electroconvulsive therapy (ECT). Which of the following information should the nurse include in the teaching. 1 - "You might experience some temporary memory loss after the procedure." 2 - "You will receive a mediation to prevent seizure activity." 3 - "These treatments should cure your depression." 4 - "You will remain asleep for about 2 hr after the procedure."

1 - "You might experience some temporary memory loss after the procedure."

A nurse is collecting data from a group of clients who have depressive disorders. Which of the following findings should the nurse expect? 1 - A focus on past successes 2 - Hallucinations 3 - A lack of energy 4 - Increased libido

3 - A lack of energy

The nurse explains that anxiety disorders different from normal anxiety. Which statement accurately describes anxiety disorders? 1 - Anxiety disorder develop into suicidal tendencies 2 - Anxiety disorders are seldom controlled 3 - Anxiety disorders interfere with effective functioning 4 - Anxiety disorders make maintenance of relationship impossible

3 - Anxiety disorders interfere with effective functioning

A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority? 1 - The client is hostile and sarcastic towards the staff 2 - The client gives personal item and money away to other clients. 3 - The client paces in the hallway during the day and most of the night 4 - The client demonstrates flight of ideas.

3 - The client paces in the hallway during the day and most of the night

A nurse is reinforcing discharge teaching for a client who will continue to take lithium carbonate at home to manage bipolar disorder. Which of the following instructions should the nurse include when reinforcing the teaching? 1 - Follow a low-sodium diet 2 - Limit daily fluid intake 3 - Withhold dose if having a fine hand tremor 4 - Avoid foods with a high tyramine content.

3 - Withhold dose if having a fine hand tremor

A patient has nightmares and thinks constantly about the sexual assault she experienced. She is seen constantly washing her hands, takes at least four showers a day, and does not go out with friends now because she is constantly cleaning her apartment. Which disorders are most related to the symptoms she is experiencing? (Select all) 1 - Mild anxiety 2 - Bipolar disorder 3 - Generalized anxiety disorder 4 - PTSD 5 - Obsessive-compulsive disorder (OCD)

4 & 5 4 - PTSD 5 - Obsessive-compulsive disorder (OCD) Rational The symptoms this person is experiencing are related to PTSD and OCD. Mild anxiety increases alertness, motivation, and attentiveness and is not what she is experiencing. Bipolar disorder is a mood disorder. Generalized anxiety disorder is associated with a person who experiences persistent, unrealistic, or excessive worry about two or more life circumstances for 6 months or longer.

What would be the appropriate response to an adolescent who states, "This has been the worst day of my life." 1 - "You should focus your mind on positive thoughts." 2 - "Everybody has a bad day now and then." 3 - "You're young. What could be so terrible." 4 - "Tell me about the worst day of your life."

4 - "Tell me about the worst day of your life."

A nurse is reinforcing teaching with a client about a new prescription for lithium. Which of the following statements should the nurse include in the teaching? 1 - "Your lithium will be discontinued in 6 months to prevent addiction." 2 - "Weight gain is a manifestation of lithium toxicity." 3 - "Your provider will prescribe a diuretic while you are taking lithium." 4 - "We will need to check your lithium levels in the next 3 to 5 days."

4 - "We will need to check your lithium levels in the next 3 to 5 days."

An important approach to the care of a 7 year old child diagnosed with attention deficit/hyperactivity disorder (ADHA) is to encourage 1 - A diet high in processed foods 2 - Regular use of sedatives 3 - Strict discipline 4 - A structured, one-on-one environment

4 - A structured, one-on-one environment

What information will best help the nurse determine whether the patient is experiencing a threat to his mental health? 1 - Opinion of family members 2 - Opinion of the health care provider 3 - Intelligence testing and educational level 4 - Appropriateness of behavior to a situation

4 - Appropriateness of behavior to a situation Rational Appropriate behavior is an indicator of mental health. Although significant, the family's opinion, health care provider's opinion, and intelligence level may not consistently correlate with mental health status.

A nurse is assisting in the development of a staff educational inservice about depression. Which of the following factors should the nurse identify as a primary risk factor for depression? 1 - Being married 2 - Pregnancy 3 - Male gender 4 - Chronic illness

4 - Chronic illness

A nurse is collecting data from a client who is taking bupropion. Which of the following findings indicates the medication is effective? 1 - Increase in weight 2 - Increase in urinary output 3 - Decreased in hallucinations 4 - Decrease in urge to smoke

4 - Decrease in urge to smoke

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting? 1 - Flight of ideas 2 - Confabulation 3 - Clang associations 4 - Grandiosity

4 - Grandiosity

A nurse at a mental health facility is discussing antidepressant medications with a newly licensed nurse, comparing selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Which of the following information should the nurse include about TCAs? 1 - Less effective in relieving depressive symptoms 2 - Low probability of causing sedation 3 - More likely to be prescribed as initial treatment 4 - Increased risk of cardiovascular adverse effects.

4 - Increased risk of cardiovascular adverse effects.

A nurse feels that there maybe a need to administer ordered medication to an older adult for anxiety. Which strategy would help the nurse to make this clinical decision? 1 - Listen to verbalization of apprehension 2 - Be sensitive to somatic complaints 3 - Initiate therapeutic communication 4 - Observe for escalation of agitation

4 - Observe for escalation of agitation Rational Escalation of agitation is a sign that medication is necessary. (1) Listening to verbalization of apprehension in itself will not help make this clinical decision. (2) Listening to somatic complaints may temporarily give the patient a sense of gratification, but the long-term goal for patients with somatic complaints may be better served by setting limits. (3) The nurse would use listening and therapeutic communication as the first-line intervention to try and help the patient gain self-control without medication; the nurse then observes to see if these measures are working.

What is an appropriate nursing intervention for a hospitalized child who is autistic? 1 - Place the child in a location where she can watch all the activity on the unit 2 - Use the child's chronological age as a guide for communication 3 - Keep the child's room free of toys or objects that she might want to take home with her 4 - Organize care to provide as few disruptions to the routine as possible

4 - Organize care to provide as few disruptions to the routine as possible

The nurse is trying a non-pharmacological intervention for a patient with anxiety. Which of the following would most likely benefit this patient? 1 - Increasing caffeine intake 2 - Decreasing physical activity 3 - Limiting noise or music in the room 4 - Performing abdominal breathing exercises

4 - Performing abdominal breathing exercises Rational Performing abdominal breathing exercises is a nonpharmacological intervention that can help decrease anxiety. Caffeine should be decreased. Physical activity is encouraged to relieve anxiety. Music can help reduce anxiety.

A nurse in an acute care mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following is the nurse's priority intervention? 1 - Discourage the client's inappropriate sexual expression 2 - Control the client's use of loud and vulgar language 3 - Maintain the client's contact with family members 4 - Protect the client and others from impulsive behavior

4 - Protect the client and others from impulsive behavior

How is a gateway substance defined? 1 - Recreational drug used occasionally 2 - Nonaddictive drug use daily 3 - Drug used to wean from stronger drugs 4 - Substance that can lead to use of stronger drugs

4 - Substance that can lead to use of stronger drugs

A nurse is reinforcing teaching with a client who is to start taking lithium for bipolar disorder. Which of the following instructions should the nurse include? 1 - Expect to loss weight while taking this medication 2 - Choose foods that are low in sodium 3 - Limit fluid intake of 1 liter per day 4 - Take lithium with meals or a glass of milk

4 - Take lithium with meals or a glass of milk

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following laboratory values? A - AST/ALT and LDH B - Creatinine and Bun C - WBC and granulocyte counts D - Serum sodium and potassium

A - AST/ALT and LDH Rational A - Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity B - Baseline levels can be drawn, but routine monitoring of creatinine and BUN is not necessary C - Baseline levels can be drawn, but routine monitoring of WBC and granulocyte is not necessary D - Baseline levels can be drawn, but routine monitoring of serum sodium and potassium is not necssary

Anxiety

A subjectively distressful experience activated by the perception of threat, which has both a potential psychological and physiological etiology and expression

A nurse is reinforcing teaching with the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the following should the nurse include? (Select all) A - Seizures B - Agitation C - Photophobia D - Dry mouth E - Irregular pulse

A, B & E A - Seizures B - Agitation E - Irregular pulse Rational C - Photophobia is an anticholinergic effect D - Dry mouth is an anticholinergic effect

A nurse is collecting data from a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all) A - Excessive worrying for 6 months B - Impulsive decision-making C - Delayed reflexes D - Restlessness E - Need for reassurance

A, D & E A - Excessive worrying for 6 months D - Restlessness E - Need for reassurance Rational B - Generalized anxiety disorder is characterized by procrastination in decision-making C - Generalized anxiety disorder is characterized by muscle tension

A nurse is caring for a client who is taking phenelzine. For which of the following adverse effects should the nurse monitor? (Select all) A - Elevated blood glucose level B - Orthostatic hypotension C - Priapism D - Headache E - Bruxism

B & D B - Orthostatic hypotension D - Headache Rational A - An elevated blood glucose level is not an adverse effect of phenelzine C - Priapism is an adverse effect of trazodone rather than phenelzine E - Bruxism is an adverse effect of SSRI's rather than phenelzine

A nurse is collecting data from a client 4 hr after an initial dose of fluoxetine. Which of the following findings should the nurse report to the RN and provider as indications of serotonin syndrome? (Select all) A - Hypothermia B - Hallucinations C - Muscular flaccidity D - Diaphoresis E - Agitation

B, D & E B - Hallucinations D - Diaphoresis E - Agitation Rational A - Fever, rather than hypothermia, is an indication of serotonin syndrome C - Muscle tremors, rather than flaccidity, are an indication of serotonin syndrome.

A nurse is a pediatric clinic is caring for a preschool-age child who has a new diagnosis of ADHD. When reinforcing teaching about this disorder with the parent, which of the following statements should the nurse include? A - "Behaviors associated with ADHD are present prior to age 3" B - "This disorder is characterized by argumentativeness." C - "Below-average intellectual functioning is associated with ADHD." D - "Because of this disorder, your child is at an increased risk for injury."

D - "Because of this disorder, your child is at an increased risk for injury." Rational A - Behaviors associated with ADHD are present before the age of 12 B - Argumentativeness is associated with oppositional defiant disorder rather than ADHA C - Below-average intellectual functioning is associated with intellectual developmental disorder rather than ADHD D - Inattentive or impulsive behavior increases the risk for injury in a child who has ADHD

A nurse is collecting the medical history from a client who has bipolar disorder and is to being talking lithium. Which of the following statements is the priority for the nurse to report to the provider? A - "I have diabetes that I control with my diet." B - "I recently completed a course of prednisone for bronchitis." C - "I received my flu vaccine last month." D - "I take furosemide for congestive heart failure."

D - "I take furosemide for congestive heart failure." Rational A,B & C - It is important to notify the provider of the client's medical history. However, this information does not pose the greatest risk to the client and is therefore not the priority. D - Diuretics, such as furosemide, are contraindicated for use with lithium due to the risk of toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A - Discuss new relaxation techniques B - Show the client how to change the behavior C - Distract the client with a television show D - Stay with the client and remain quiet

D - Stay with the client and remain quiet Rational A - During a panic attack, the client is unable to concentrate on learning new information B - During a panic attack, the client is unable to concentrate on learning new information C - During a panic attack, the nurse should avoid further stimuli that can increase the client's level of anxiety D - Durning a panic attack the nurse should quietly remain with the client. This promotes safety and reassurance without additional stimuli

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take? A. Discuss new relaxation techniques. B. Show the client how to change the behavior. C. Distract the client with a television show D. Stay with the client and remain quiet.

D. Stay with the client and remain quiet.

Parents request guidance and seek help referral to:

Family care provider pediatrician community mental health center psychiatric clinical nurse specialties (CNS) School psychologist/guidance counselor

Nervous tension and anxiety in children

Finger sucking, nail biting, excessive fears, stuttering, and conduct problems

List the four predominant coping patterns of children of alcoholics.

Flight, fight, the perfect child, and the super-coper or family savior.

OCD Medication

Fluoxetine, Sertraline and fluvoxamine

Mental Health General Risk Factors

Genetic links or chromosomal abnormalities, Biochemical, Social and environmental, Cultural and ethnic, Resiliency, Witnessing or experiencing traumatic events

HELP

H: offer Hope E: demonstrate Empathy L: and Loyalty P: and Participate

Second-line medications

MAOI's

6th Vital Sign

Mental Status Assessment Ability to process information is the purpose of the. mental status assessment appearance, motor function, speech/content, cognitive processes - perception, judgment, insight, and memory, alertness and orientation

Lithium toxicity

Narrow therapeutic range 0.8 -1.4 mEq/L Toxic range 1.5 mEq/L Diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination, Severe symptoms - ataxia, giddiness, tinnitus, blurred vision, large output of dilute urine Long-term side effects - thirst, frequent urination, tremors, diarrhea, weight gain, and edema -not to be takin my pregnant women

Antidressant's

Once the antidepressant medications begin to take effect, the risk for self-harm actually increases, because the patient now has sufficient energy to complete the act

Manic Spectrum

Presence of euphoric or agitated affective states - perceptual disturbances - racing thoughts - grandiose delusions, difficulty concentrations, impulsivity, and lack of insight - reckless and dangerous

First line choice for depression treatments

SSRI's - takes 3 weeks

First-line medications

TCA's, SSRI's, SNRI's

flight or fight response

The flight-or-fight response is a response that occurs when an organism confronted with a threatening situation prepares to fight or flee. This response is controlled by the sympathetic system. This response includes rising heart and respiration rates, constriction of blood vessels, increase in the levels of glucose in your body, and "goose bumps" on your skin.

Behavioral therapy

changing patterns of behavior that are repeated over time with negative results

suicidal situations

loss- a loved one or pet, separation, illness, employment status, and self-esteem behavioral signals - suicidal ideation - writing or creating art about death, giving away prized possessions, joking about death, dying suicide or leaving

Undiagnosed mood state characterized by sadness, despair, and loss of function status

melancholy

Serotonin toxicity/syndrom

tachycardia, shivering, diaphoresis, dilated pupils, myoclonus, hyperreflexia, hyperthermia 30 minutes to 48 hours after taking medication Change of mental status, increase in pulse and fluctuation in BL, loss of muscle coordination and hyperthermia

Affect

the observable response a person has to his or her own feelings mood, energy, and cognition

Mood

the way a person feels

Cognitive therapy

therapy that teaches people new, more adaptive ways of thinking and acting; based on the assumption that thoughts intervene between events and our emotional reactions attempts to change thoughts and beliefs - repetitive dysfunctional patters

Which response to anxiety is cause for concern? 1 - A pilot has a small alcoholic drink before his scheduled flight 2 - A nursing student stays up most of the night to study for an upcoming examination 3 - A man asks several of his friends for opinions before asking a woman out on a date 4 - A woman takes several deep breaths before going into the grocery store because shopping makes her nervous

1 - A pilot has a small alcoholic drink before his scheduled flight Rational Ingesting alcohol before a flight is likely to impair the pilot's judgment and put the pilot and others at high risk for injury. Staying up all night to study, asking several friends for opinions before asking a woman on a date, and taking deep breaths before doing something that causes anxiety are appropriate responses to anxiety.

A nurse is reviewing the morning laboratory report for a client who has bipolar disorder and recently started taking lithium. The client's current lithium level is 1.2 mEq/L. Which of the following actions should the nurse plan to take? 1 - Administer the regular dose of lithium 2 - Obtain an ECG and institute seizure precautions 3 - Contact the provider to prescribe an increase dose of lithium 4 - Contact the laboratory to repeat the lithium levels

1 - Administer the regular dose of lithium

A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety? 1 - Incoherent speech 2 - Irritability 3 - Chest pain 4 - Insomnia

1 - Incoherent speech

The nurse is caring for a suicidal patient who has been treated effectively with antidepressant therapy. The patient verbalizes that he feels better. The nurse is alert that the patient is most at risk for which potential complication? 1 - Increased risk for self-harm 2 - Increased emotional fragility 3 - Increased potential for weight gain 4 - Increased activity intolerance

1 - Increased risk for self-harm

A patient who is taking an SSRI suddenly develops a rapid pulse, fluctuating blood pressure, fever, loss of muscle coordination, and mental status changes. The nurse anticipates that the provider is most likely to order which medical therapy? 1 - Infuse IV fluids and administer an antipyretic 2 - Obtain an electrocardiogram and start oxygen through a nasal cannula 3 - Administer an antidote and encourage oral fluids 4 - Monitor the patient closely and continue the medication

1 - Infuse IV fluids and administer an antipyretic Rational Patient is manifesting symptoms of serotonin syndrome. This is a potential life-threatening condition that could start 30 minutes to 48 hours after taking the medication. Treatment includes stopping medication, administering IV fluids, and decreasing temperature. (2) Possibly the health care provider may order an electrocardiogram (ECG) to rule out other problems, and giving oxygen for change of mental status is acceptable if pulmonary problems are suspected. (3) There is no single antidote for this condition, and PO fluids are inappropriate for patients who are unstable. (4) Close monitoring is necessary, but the medications should be discontinued.

The nurse is educating a patient with a new prescription for lithium carbonate. Which information is most important for the nurse to include in the teaching plan? 1 - It can take up to two weeks for lithium to each a therapeutic level in the body 2 - Lithium is often given in conjunction with loop diuretics. 3 - Carefully restrict sodium intake to less than 1 gram/day 4 - Take medication before breakfast for maximum effectiveness

1 - It can take up to two weeks for lithium to each a therapeutic level in the body

A nurse is caring for a client who has bipolar disorder an is experiencing acute mania. Which of the following is an appropriate food choice for this client? 1 - Peanut butter sandwich 2 - Soup 3 - Spaghetti 4 - Oatmeal

1 - Peanut butter sandwich

A nurse is collecting data from a newly admitted client who has major depressive disorder. Which of the following findings should the nurse expect? 1 - Psychomotor retardation 2 - Ritualistic behaviors 3 - Impulsivity 4 - Clang associations

1 - Psychomotor retardation

When describing the result of the fight or flight response, the nursing student requires further teaching when making which statement? 1 - Pupils constrict when a patient is anxious 2 - The heart races when a patient experiences anxiety 3 - Peristalsis slows as the patient decided whether to fight back 4 - The patient may complain of dry mouth when anxious

1 - Pupils constrict when a patient is anxious Rational Arousal of the sympathetic division of the autonomic nervous system leads to the release of adrenalin which causes the heart to speed up and circulate blood faster, the lungs to dilate to increase the oxygen carrying capacity of the blood, the liver to release stored glucose for a quick infusion of energy, the pupils to dilate for improved visual acuity, and the stomach to inhibit peristalsis as a means to conserve energy. Secondary to these organ system changes, there are observable signs of the "Fight or Flight" response that include tachycardia, disambiguation, bladder relaxation, tremors, blushing, xerostomia, delayed digestion, and hyperacusis.

A nurse is caring for a client who has depression and a new prescription for bupropion. The nurse should collect data from the client regarding which of the following contraindications for taking bupropion? 1 - Recent head trauma 2 - Current elevated cholesterol levels 3 - History of thyroid disease 4 - History of glaucoma

1 - Recent head trauma

A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take? 1 - Reinforce how to use assertive communication techniques. 2 - Schedule the client's daily self-care activities. 3 - Set short-term and long-term goals for the client 4 - Discourage the client from expressing anger

1 - Reinforce how to use assertive communication techniques.

A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first? 1 - Remain with the client 2 - Provide an activity for diversion 3 - Encourage verbalization of feelings 4 - Have the client identify two coping skills

1 - Remain with the client

A nurse is collecting data from client who has just begun therapy with alprazolam to treat anxiety. The nurse should observe the client for which of the following adverse effects fo this medication? 1 - Sedation 2 - Bradycardia 3 - Hearing loss 4 - Hypertension

1 - Sedation

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect? 1 - Significant change in weight 2 - Hyper-excitability 3 - Exaggerated response of pleasure to stimuli 4 - Attention-seeking behavior

1 - Significant change in weight

A nurse is reinforcing teaching with a client who has a new prescription for lithium carbonate to treat bipolar disorder. The nurse should make sure the client understands that he must maintain consistency in his intake of which of the following dietary elements? 1 - Sodium 2 - Potassium 3 - Vitamin K 4 - Vitamin C

1 - Sodium

The nurse is caring for a patient receiving lithium for bipolar disorder. The nurse knows to check the patient's laboratory levels of which electrolyte before administering the medication? 1 - Sodium 2 - Chloride 3 - Potassium 4 - Magnesium

1 - Sodium Rational Approximately 80% of the lithium dose is absorbed in the proximal tubule of the kidney. The amount of reabsorption depends on the concentration of sodium; a sodium deficiency causes greater absorption, leading to lithium toxicity. Lithium dosage is not related to chloride, potassium, or magnesium.

The nurse is caring for a patient with moderate anxiety. Which activity should the nurse encourage to best manage the patient's anxiety? 1 - Taking a walk 2 - Learning a new game 3 - Watching an intense television shop 4 - Reading a pamphlet about the negative effects of anxiety

1 - Taking a walk

A nurse is reinforcing teaching with a client who takes lithium carbonate for bipolar disorder. For which of the following findings should the nurse monitor as an adverse effect of lithium carbonate? 1 - Thyroid enlargement 2 - Constipation 3 - Elevated blood pressure 4 - Hyporeflexia

1 - Thyroid enlargement

A nurse is collecting data from a client who is to start taking amitriptyline for depression. Which of the following dietary supplements should the nurse instruct the client to avoid? 1 - Valerian 2 - Echinacea 3 - Feverfew 4 - Garlic

1 - Valerian

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take? 1 - Walk with the client at a gradually slowing pace 2 - Allow the client to pace alone until physically tired 3 - Ask a small group of other clients to walk with the client 4 - Calmly instruct the client to stop pacing and sit in the dayroom.

1 - Walk with the client at a gradually slowing pace

The most commonly abused substance among adolescents is: 1)alcohol. 2)marijuana. 3)heroin. 4)narcotics.

1)alcohol

A nurse is reinforcing teaching with a group of adolescents regarding identifying behavioral indictors of depression, Which of the following manifestations should the nurse include? (Select all) 1 - Irritability 2 - Decreased energy 3 - Grandiosity 4 - Isolation from peers 5 - Euphoria

1, 2, & 4 1 - Irritability 2 - Decreased energy 4 - Isolation from peers

A nurse is preparing to assist with the care of a client who is to undergo electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to treatment? (Select all) 1 - Electroencephalogram (EEG) monitor 2 - Oxygen saturation monitor 3 - Flexible sigmoidoscope 4 - Electrocardiogram (ECG) monitor 5 - Portable x-ray machine

1, 2, & 4 1 - Electroencephalogram (EEG) monitor 2 - Oxygen saturation monitor 4 - Electrocardiogram (ECG) monitor

The nurse outlines the treatment for a person with anxiety disorder, which includes which of the following (Select all) 1 - Relaxation techniques 2 - Stress management 3 - Anxiolytic medication 4 - Individual therapy 5 - Education about disorder

1, 2, 3, 4, & 5 1 - Relaxation techniques 2 - Stress management 3 - Anxiolytic medication 4 - Individual therapy 5 - Education about disorder

A patient demonstrates an overwhelming feeling of worthlessness, difficulty in making decisions or concentrating, and suicidal thoughts. The nurse determines the suicide risk by asking which questions(s) (Select all) 1 - "Are you feeling suicidal?" 2 - "Do you have a plan? How do you plan to take your life?" 3 - "Why do you want to commit suicide?" 4 - "What would you accomplish by killing yourself?" 5 - "Do you drink or use drugs on a regular basis?" 6 - "Have you considered how your family would feel?" 7 - "Have you recently given away any of your belongings?"

1, 2, 5 & 7 1 - "Are you feeling suicidal?" 2 - "Do you have a plan? How do you plan to take your life?" 5 - "Do you drink or use drugs on a regular basis?" 7 - "Have you recently given away any of your belongings?" Rational Suicidal feelings, having a plan, and substance abuse are factors that increase the likelihood of suicide attempt. Giving away belongings is a sign of the patient saying good-bye. (3, 4, 6) These types of questions are less about risk than they are about motivation. The psychiatrist or psychologist can pursue these issues because of the depth and follow-up that are required.

A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? (Select all) 1 - Poor eye contact 2 - Increased fever 3 - Appetite changes 4 - Increased white blood cell count 5 - Slowed speech

1, 3 & 5 1 - Poor eye contact 3 - Appetite changes 5 - Slowed speech Rational Typical signs of depression include sleep disturbance; poor eye contact; loss of interest in events; guilt; decreased energy, speech, and concentration; appetite changes; and slowed motor movements. Increased fever and white blood cell count are indicative of infection, not depression.

Which of the following statements is true regarding anxiety? (Select all) 1 - Anxiety is a response to stress 2 - Anxiety is uncommon in women 3 - Anxiety can cause elevation in blood pressure and hear rate 4 - Many conditions are exacerbated by stress and anxiety 5 - Patients with anxiety respond well to relaxation techniques 6 - Children are at the highest risk for anxiety

1, 3, 4 & 5 1 - Anxiety is a response to stress 3 - Anxiety can cause elevation in blood pressure and hear rate 4 - Many conditions are exacerbated by stress and anxiety 5 - Patients with anxiety respond well to relaxation techniques Rational Adults and the elderly are at the highest risk for anxiety. Anxiety is more common in women.

The nurse is assessing a patient's anxiety related to stress Which changes reflect the short-term physiological response to stress? (Select all) 1 - Cortisol is released, increasing glycogenesis and reducing fluid loss 2 - Immune system functioning decreases, and the risk of cancer increases 3 - Corticosteroid release increase stamina and impedes digestion 4 - Muscular tension, blood pressure, and triglyceride levels increase 5 - Epinephrine is released, increasing the heart and respiratory rates 6 - Risk of depression, autoimmune disorders, and heart disease increases

1, 3, 4 &5 1 - Cortisol is released, increasing glycogenesis and reducing fluid loss 3 - Corticosteroid release increase stamina and impedes digestion 4 - Muscular tension, blood pressure, and triglyceride levels increase 5 - Epinephrine is released, increasing the heart and respiratory rates Rational The correct answers are all short-term physiological responses to stress. Increased risk of immune system dysfunction, cancer, cardiovascular disease, depression, and autoimmune disease are all long-term (chronic) effects of stress.

A nurse is caring for a client who is experiencing acute anxiety. Which of the following actions should the nurse take (Select All) 1 - Avoid eye contact when addressing the client 2 - Establish rapport with the client 3 - Identify the cause of the anxiety 4 - Validate the client's feelings 5 - Speak to the client using a high-pitched voice.

2, 3, 4 2 - Establish rapport with the client 3 - Identify the cause of the anxiety 4 - Validate the client's feelings

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all) 1 - Assess for bradycardia 2 - Ask about epigastric pain 3 - Observe for increased appetite 4 - Check for elevated blood glucose level 5 - Monitor for a decrease in respiratory rate

2, 3 & 4 2 - Ask about epigastric pain 3 - Observe for increased appetite 4 - Check for elevated blood glucose level Rational The physiological changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in respiratory and heart rates.

A nurse is reinforcing teaching with a client who has a major depressive disorder and a new prescription for fluoxetine. Which of the following statements should the nurse make to the client? 1 - "You should plan to eat several snacks every day because fluoxetine causes weight loss." 2 - "You could experience withdrawal manifestations if you stop taking fluoxetine abruptly." 3 - "You are likely to experience dizziness or fainting if you get up out of bed quickly." 4 - "You can take fluoxetine with St. John's wort to obtain increased antidepressant effects."

2 - "You could experience withdrawal manifestations if you stop taking fluoxetine abruptly."

A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing others clients with incessant talking. Which of the following actions should the nurse take? 1 - Allow the client to interact freely with others on the unit 2 - Assist the client to practice social interaction with peers during a community meeting 3 - Escort the client to her room when she is observed trying to interact with other clients 4 - Inform the client that restraints may be necessary if she cannot control her behavior.

2 - Assist the client to practice social interaction with peers during a community meeting

A nurse is contributing to the plan of care for a client who has prescription for electroconvulsive therapy (ECT). Which of the following medications should the nurse prepare to administer prior to the treatment. 1 - Levodopa 2 - Atropine 3 - Epinephrine 4 - Haloperidol

2 - Atropine

A patient is taking lithium. Which are early signs of lithium toxicity? 1 - Hypertension and headache 2 - Diarrhea and slurred speech 3 - Confusion and blurred vision 4 - Convulsion and polyuria

2 - Diarrhea and slurred speech Rational Diarrhea and slurred speech are early signs. (3) Confusion, blurred vision, convulsion, and polyuria are late signs. (1) Hypertension and headache are more associated with the MAOI antidepressants. (4) Convulsions and polyuria are not signs of lithium toxicity. Sodium depletion and dehydration may cause toxicity.

A nurse caring for a client who has a spinal cord injury and is at risk for depression. Which of the following findings should the nurse identify as an indication that the client is developing depression? 1 - Flight of ideas 2 - Difficulty concentrating 3 - Feeling of grandeur 4 - Paranoia

2 - Difficulty concentrating

A military veteran is admitted to your unit with a diagnosis of chronic post-traumatic stress disorder (PTSD). After being placed in the treatment room, he begins to pace frantically and make references to "Highway 1." As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tightly to his body. This patient is most likely experiencing which occurrence? 1 - Delusion 2 - Flashback 3 - Hallucination 4 - Phobic reaction

2 - Flashback Rational This patient's symptoms are consistent with a flashback secondary to PTSD. Hallucinations and delusions are associated with psychotic disorders such as schizophrenia. Phobic reactions are not associated with the symptoms this patient is exhibiting.

The nurse explains that the use of stimulants will decrease hyperactivity in the autistic child. What is a negative aspect of stimulants? 1 - Sedating the child 2 - Impairing cognition 3 - Causing hypotension 4 - Creating fluid retention

2 - Impairing cognition

A child is diagnosed with attention deficit hyperactivity disorder (ADHD). Which characteristics would the nurse assess in the child? Select all 1 - Social anxiety 2 - Impulsivity 3 - Hyperactivity 4 - Distractibility 5 - Inattention

2, 3, 4 & 5 2 - Impulsivity 3 - Hyperactivity 4 - Distractibility 5 - Inattention

A patient is hospitalized for dehydration and weight loss. She is very restless and exhibits flight of ideas with easy distractibility. Which intervention is most appropriate for the problem of inadequate nutrition? 1 - Give three high-calorie meals on a regular schedule 2 - Offer finger foods, such as a meat and cheese sandwich 3 - Provide a pleasant, odor-free environment 4 - Encourage family meals and socialization while eating

2 - Offer finger foods, such as a meat and cheese sandwich Rational Offering foods that can be consumed "on the run" will increase the likelihood that the patient will eat something. (1) High-calorie foods are a good idea, but a regular schedule is going to be difficult for this patient at this point. (3) A pleasant, odor-free environment will not hurt, but it is more appropriate for patients who have anorexia related to nausea or for older patients. (4) Socialization for this patient is likely to cause distraction and results in decreased intake.

A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the nurse take? 1 - Engage the client in a small group activity 2 - Offer the client high-calorie foods and fluids frequently 3 - Play loud music for the client in her room 4 - Instruct the client to avoid napping during the day

2 - Offer the client high-calorie foods and fluids frequently

A nurse is caring for a client whose spouse died in a traumatic accident. Which of the following findings should the nurse manager identify as an indication of clinical depression? 1 - Open expression of anger 2 - Persistent dysphoria 3 - Identification of the specific cause of sadness 4 - Alternating days of feeling sad and hopeful

2 - Persistent dysphoria

When assessing an 8 year old child with obsessive compulsive disorder (OCD), the nurse would expect to find 1 - An intelligence deficit 2 - Ritualistic behavior 3 - Antisocial behavior 4 - Combative behavior

2 - Ritualistic behavior

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? 1 - Anxiety 2 - Seasonal affective disorder 3 - Medication side effects 4 - Antisocial personality

2 - Seasonal affective disorder Rational Decreased exposure to sunlight in winter months can reduce the production of serotonin in the brain, leading to a type of depression termed seasonal affective disorder; this tends to resolve with the longer days and increased exposure to sun of spring and summer. There are not enough data to identify anxiety or signs linked to medication, which also tend to not resolve with seasons. Antisocial traits include isolation but also include behaviors of manipulation and lack of remorse in interpersonal relationships.

A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? 1 - Primary prevention 2 - Secondary prevention 3 - Tertiary prevention 4 - Modified prevention

2 - Secondary prevention Rational Secondary prevention is aimed at early detection of problems, in this case, the identification of depression for early intervention. Primary prevention for mood disorders focuses on stress reduction and societal issues such as reducing poverty and racism. Tertiary prevention aims to reduce disability from a diagnosed condition; for mood disorders, this includes prevention of relapse and protection from harm. Modified prevention is not a recognized level of prevention, although prevention interventions may need to be adapted to meet specific individual situations.

A patient displaying mania is investigating the unit and overseeing the activities of other patients; because of these behaviors, she is unable to finish her dinner. The nurse should institute which intervention to ensure proper nourishment for this patient? 1 - Server her small, attractively arranged portions 2 - Serve high-calorie foods she can carry with her 3- Encourage her appetite by ordering out for her favorite foods 4 - Allow her in the unit kitchen for extra food whenever she wishes

2 - Serve high-calorie foods she can carry with her Rational During periods of mania, the patient may be unable to sit long enough to complete a meal. Providing high-calorie finger foods will allow the patient to move around the unit while maintaining adequate nutrition. Attractively arranged portions, providing the patient's favorite foods, and allowing the patient to enter the unit kitchen whenever she likes would not help this patient attain proper nourishment.

A nurse is contributing to the plan of care for a newly-admitted client who has severe depressive disorder. Which of the following interventions should the nurse include in the plan? 1 - Give the client choices of activities 2 - Spend time with the client 3 - Play a game of chess with the client 4 - Encourage the client to make decisions.

2 - Spend time with the client

A nurse is reinforcing teaching with a client who is to start taking lithium carbonate. Which of the following dietary supplements should the nurse instruct the client to avoid? 1 - Black cohosh 2 - St. John's wort 3 - Ginkgo biloba 4 - Ginger root

2 - St. John's wort

While sitting at the nurse's station, the nurse observes a patient using a tissue to pick up magazines and change the television channels. The nurse recognizes this as a new behavior for this patient. Which nursing action would be most important? 1 - Taking the tissues away from the patient 2 - Talking with the patient about the behavior 3 - Providing the patient with non-sterile gloves 4 - Recognizing the behavior as attention-seeking

2 - Talking with the patient about the behavior Rational The nurse should question the patient regarding any changes in behavior to determine responses to treatment. It would not be therapeutic for the patient to have the tissues taken away, to be provided with nonsterile gloves, or to have the behavior recognized as attention-seeking.

A nurse is caring for a client who has depression. When the nurse encourages the client to join an activity the client states, "What's the use?" Which of the following is an appropriate nursing intervention? 1 - Sit down with the client and ask her why she doesn't want to participate 2 - Tell the client that it is time for the activity, and accompany her to the activity. 3 - Convince the client how helpful it will be to engage in the activity 4 - Tell the client that she has a self-defeating attitude and it will only make her feel worse.

2 - Tell the client that it is time for the activity, and accompany her to the activity.

A nurse is reviewing a pamphlet about sertraline with a client who has post-traumatic stress disorder. Which of the following client statements indicates understanding of the information? 1 - "I need to decrease my sodium intake while on this medication." 2 - "This medication can cause a dry cough." 3 - "I should call the provider if I experience excessive sweating and muscle twitching." 4 - "This medication can cause harmless, temporary changes to my ability to taste and smell."

3 - "I should call the provider if I experience excessive sweating and muscle twitching."

A nurse is reinforcing teaching with a client who has a new prescription for fluoxetine. Which of the following instructions should the nurse include? 1 - "Avoid foods that contain tyramine." 2 - "Plan to discontinue this medication as soon as your depression is relieved." 3 - "Expect that your mood might take one to three weeks to being improving." 4 - "Stop taking this medication if weight loss or gain occurs."

3 - "Expect that your mood might take one to three weeks to being improving."

A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate? 1 - "You really need to follow the rules of the unit and get out of bed." 2 - "If you do not get out of bed, you will not receive your meal." 3 - "I will help you sit up and get your slippers on." 4 - "You should rest in bed until you feel able to take part in unit activities."

3 - "I will help you sit up and get your slippers on."

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? 1 - "I will call your care provider. Perhaps you need a different medication." 2 - "Don't worry. We can try taking it at a different time of day to help it work better." 3 - "It usually takes a few weeks for you to notice improvement from this medication." 4 - "Your life is much better now. You will feel better soon."

3 - "It usually takes a few weeks for you to notice improvement from this medication." Rational Seeing a response to antidepressants takes 3 to 6 weeks. No change in medication is indicated at this point of treatment, because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that his or her life is better does not acknowledge the patient's feelings.

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT). Which of the following client statements indicates to the nurse a need for further teaching? 1 - "I will receive medication to make me sleep during the procedure." 2 - "I will undergo treatments for 6 weeks." 3 - "My memory loss will last several minutes after treatment." 4 - "The nurse will monitor me closely for seizure activity."

3 - "My memory loss will last several minutes after treatment."

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? 1 - "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite." 2- "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." 3 - "The person may have excess energy, talk a lot, feel restless, and spend too much money." 4 - "The person may experience decreased energy and interest in activities beginning in the winter months."

3 - "The person may have excess energy, talk a lot, feel restless, and spend too much money." Rational Signs that a person is cycling into a manic phase include sleeping and eating less and having increased energy and racing thoughts, increased impulsivity, and increased spending behaviors. Blood pressure may increase related to increased activity, but increased blood pressure and food cravings alone are not indicative of mania. Increased sleep and poor appetite and hygiene are indicative of depression. Decreased energy in winter seasons is indicative of seasonal affective disorder related to decreased sunlight.

A nurse is reinforcing dietary teaching for a client who is to start taking a monoamine oxidase inhibitor (MAOI). Which of the following food choices should the nurse identify as having the highest tyramine content. 1 - 2% milk 2 - Celery Sticks 3 - Avocados 4 - Sliced apples

3 - Avocados

What is the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder (ADHD) for the school nurse to suggest? 1 - Seat the child in the back of the room to prevent distraction for other children 2 - Pair the child with a student buddy to offer reminders to pay attention 3 - Divide work assignments into shorter periods with breaks in between 4 - Separate the child from others to increase his focus on schoolwork

3 - Divide work assignments into shorter periods with breaks in between

A 46- year-old women is diagnosed with generalized anxiety disorder. Which behavior is more likely to be displayed with this diagnosis? 1 - Runs out of the room when she notices a spider in the corner 2 - Continuously checks to see if doors are shut and locked 3 - Has difficulty concentrating and excessively worries about her family 4 - Wakes at night screaming because of recurrent nightmares

3 - Has difficulty concentrating and excessively worries about her family Rational Difficulty concentrating and excessive worry are part of diagnostic criteria for general anxiety disorder (GAD). (1) Excessive fear of spiders is an example of phobic disorder; (2) Repetitive checking and rechecking doors is an example of behavior associated with obsessive-compulsive disorder; (4) Recurrent nightmares are associated with post-traumatic stress disorder (PTSD).

A resident in a long-term care facility has been in a manic stage for 2 days. He has not slept and cannot focus long enough to eat a meal. How should the nurse best enhance the resident's nutrition? 1 - Insist he sit down and eat at the table 2 - Spoon-feed him at the table at regular mealtimes. 3 - Offer him small glasses of high-protein drinks every hour 4 - Make up a game about who can finish a meal first

3 - Offer him small glasses of high-protein drinks every hour

A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a substance use disorder. He tells the nurse that he first began using illicit drugs when his parents wouldn't allow him to get a tattoo. Which of the following defense mechanisms is the client demonstrating? 1 - Suppression 2 - Intellectualization 3 - Projection 4 - Dissociation

3 - Projection

Which nursing action is appropriate immediately after a patient receives electroconvulsive therapy (ECT)? 1 - Administering oxygen at 6 L/min 2 - Restraining the patient for 24 hours 3 - Remaining with the patient until she becomes oriented 4 - Discharging the patient home with instructions to rest for the following 24 hours

3 - Remaining with the patient until she becomes oriented Rational Patients are often disoriented after ECT; maintaining safety is a primary goal at this time. Oxygen is not standard treatment after ECT. Restraints are unnecessary and inappropriate. The patient should not be discharged until she is oriented and safety is ensured.

A nurse in an urgent care clinic is caring for a client who is using loud and rapid speech, and continuously repeats "I don't know why my wife left me." Which of the following levels of anxiety is the client experiencing? 1 - Mild 2 - Moderate 3 - Severe 4 - Panic

3 - Severe

A patient is irritable, pacing, crying, and becoming increasingly agitated. A nursing intervention that could be helpful is 1 - Initiate a contract stating suicide won't be attempted 2 - Administer ordered antidepressant medication 3 - Stay with the patient and make the surroundings less stimulating 4 - Offer small nourishing meals and finger foods to sustain nutrition

3 - Stay with the patient and make the surroundings less stimulating Rational Making the area less stimulating and staying with the patient can lower anxiety. (1) The patient is not displaying signs of intending to commit suicide; (2) antidepressant medication is not appropriate in this situation; (4) the patient is exhibiting signs of anxiety, not of hyperactivity. Small nourishing meals and finger foods to sustain nutrition are more important for the patient with dementia who will not stay still.

A nurse is caring for a client who has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first? 1 - Ask the client what precipitated this anxiety 2 - Offer the client a prescribed anti-anxiety medication 3 - Tell the client you will remain with her 4 - Take the client to a quiet room

3 - Tell the client you will remain with her

A depressed patient is threatening to harm himself. Which nursing action indicated an understanding of the appropriate care of the suicidal patient? 1 - The nurse administers a sedative 2 - The nurse places the patient in seclusion 3 - The nurse asks the patient if he has a plan 4 - The nurse calls the family and asks them to visit the patient

3 - The nurse asks the patient if he has a plan Rational When a patient is threatening suicide, is it crucial to ask if the patient has a specific plan to determine the patient's risk. Sedative administration, seclusion, and family visits are not the appropriate interventions for a patient threatening suicide.

A nurse is reinforcing teaching with a client who has a prescription for lithium carbonate to treat bipolar disorder. Which of the following instructions should the nurse include? 1 - Follow a low-sodium diet 2 - Take the medication on an empty stomach 3 - Wait up to 3 weeks to see the full effects of the medication 4 - Limit fluid intake to 800 ounce per day while taking this medication

3 - Wait up to 3 weeks to see the full effects of the medication

A patient is disheveled and disinterested in daily activities such as bathing or hygiene. She reports overwhelming feeling of sadness and loss of energy. A problem of altered self-care deficit regarding bathing and hygiene is identified. Which intervention(s) would be appropriate? (Select all) 1 - Explain the importance of hygiene to health and appearance 2 - Encourage the patient to "look good and fell good." 3 - Plan extra time to help the patient to complete ADLs related to hygiene 4 - Instruct the nursing assistant to do partial hygiene 5 - Encourage some participation and set limits. 6 - Do everything for the patient until she feels better 7 - Have the same caregiver assist on a daily basis if possible

3, 4, 5 & 7 3 - Plan extra time to help the patient to complete ADLs related to hygiene 4 - Instruct the nursing assistant to do partial hygiene 5 - Encourage some participation and set limits. 7 - Have the same caregiver assist on a daily basis if possible Rational Allowing for extra time, practicing partial hygiene (washing face, brushing teeth), and having the same caregiver will help the patient gradually resume self-care. In addition, the patient should be expected to do something for herself even if the action is very limited in the beginning (e.g., holds the washcloth), and the nurse must set the expectation that he will help as much as possible. (1) Explaining the importance of hygiene or trying to point out the relationship of appearance to feelings is not appropriate when the patient is deeply depressed. (2) Encouraging the patient to "look good and feel good" is not appropriate when the patient until the patient is less depressed. (6) Doing everything for a patient is never the best option unless the patient is unable to do anything for self (comatose or catatonic).

A nurse is reinforcing teaching with a client who is to being taking paroxetine. Which of the following statements by the client indicates an understanding of the teaching? 1 - "I might experience an increase desire to have sex." 2 - "My blood pressure might increase." 3 - "I might notice that I have more saliva." 4 - "I might not feel like eating as much."

4 - "I might not feel like eating as much."

A nurse is reinforcing teaching for a client who is depressed and has a prescription for fluoxetine 20 mg PO twice daily. The nurse should identify that which of the following statements by the client demonstrates an understanding of the teaching? 1 - "I'll take my second dose of this medicine at bedtime." 2 - "I should avoid eating cheese while taking this medication." 3 - "I can stop taking this medication if I'm feeling better after the first month." 4 - "I'll need to report weight loss or gain to my provider while taking this medication."

4 - "I'll need to report weight loss or gain to my provider while taking this medication."

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement client might use to treat the symptoms of depression? 1 - Valerian 2 - Feverfew 3 - Ginkgo biloba 4 - St. John's wort

4 - St. John's wort

A nurse is collecting data from a client who is experiencing moderate anxiety. Which of the following findings should the nurse expect? 1 - The client's communications are difficult to understand 2 - The client is unable to learn new information 3 - The client expresses feelings of impending doom. 4 - The client has a narrowed focus of attention.

4 - The client has a narrowed focus of attention. Rational 1- The nurse may have a difficult time understanding communication from a client who is experiencing severe anxiety. However, A client who is experiencing moderate anxiety is more likely to have voice tremors and pitch changes. 2 - A client who is experiencing severe anxiety is likely to be unable to learn or function. However, A client who is experiencing moderate anxiety is more likely to have slightly impaired learning ability. 3 - A client who is experiencing severe anxiety is likely to experience feelings of impending doom. However, A client who is experiencing moderate anxiety is more likely to have mild gastric symptoms. 4 - A client who is experiencing moderate anxiety is likely able to focus on a task but can be selectively inattentive.

A nurse is assisting with an admission assessment for a client who has vegetative signs of depression. Which of the following is an appropriate intervention to recommend including in the plan of care? 1 - Discourage rest only at bedtime 2 - Instruct family to avoid visiting during mealtimes. 3 - Offer frequent, low-calorie snacks. 4 -Developing a structured routine for the client to follow.

4 -Developing a structured routine for the client to follow.

A nurse is caring for a client who has acute stress disorder and is experiencing sever anxiety. Which of the following statements should the nurse make? A - "Tell me about how you are feeling right now." B - "You should focus on the positive things in your life to decrease your anxiety." C - "Why do you believe you are experiencing this anxiety?" D - Let's discuss the medications your provider is prescribing to decrease your anxiety."

A - "Tell me about how you are feeling right now." Rational A - Asking an open-ended questions is therapeutic and assists the client in identifying anxiety B - Offering advice is non-therapeutic and can hinder further communication C - Asking the client a "why" question is non-therapeutic and can promote a defensive client response D - Postpone health teaching until after acute anxiety subsides. Clients experience severe anxiety are unable to concentrate or learn.

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A - "This medication increases the release of serotonin and norepinephrine." B - "I will need to monitor the client for hyponatremia while taking this medication." C - "This medication is contraindicated for clients who have an eating disorder." D - "Sexual dysfunction is a common adverse effect of this medication."

A - "This medication increases the release of serotonin and norepinephrine." Rational A - Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine B - Hyponatremia is an adverse effect of venlafaxine, rather than mirtazapine C - Bupropion, rather than mirtazapine, is contraindicated in clients who have an eating disorder D - Sexual dysfunction is an adverse effect of SSRI's rather than mirtazapine.

A nurse is preparing to administer medication to a client who is experiencing extreme mania due to bipolar disorder. The client's serum lithium level is 1.2 mEq/L. Which of the following actions should the nurse take? A - Administer the next dose of lithium carbonate as scheduled B - Prepare for administration of aminophylline C - Notify the provider for a possible increase in the dosage of lithium carbonate D - Request a stat repeat of the lithium blood level.

A - Administer the next dose of lithium carbonate as scheduled Rational A - During a manic episode, the lithium blood level should be 0.8 to 1.4 mEq/L. It is appropriate to administer the next dose as scheduled B - Aminophylline can be prescribed for treatment of sever toxicity for levels greater than 1.5 mEq/L C - A dosage increase would place the client at risk for toxicity and is therefore not an appropriate action D - A lithium level of 1.2 mEq/L is an expected finding for a client who is experiencing a manic episode. It is not necessary to request a stat repeat of laboratory test.

A nurse is caring for a client who takes paroxetine to treat post-traumatic stress disorder. The client states that he grinds his teeth during the night, which causes pain in his mouth. The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all) A - Concurrent administration of buspirone B - Administration of a different SSRI C - Use of a mouth guard D - Changing to a different class of anti-anxiety medication E - Increasing the dose of paroxetine

A, C & D A - Concurrent administration of buspirone C - Use of a mouth guard D - Changing to a different class of anti-anxiety medication Rational B - Other SSRI's will also have bruxism as an adverse effect. This is not an effective measure E - Increasing the dose of paroxetine can cause bruxism to worsen. This is not an effective measure.

A nurse is assisting with the plan of care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A - Determine the client's risk of self-harm B - Instill hope for positive outcomes C - Encourage the client to participate in group therapy sessions D - Encourage the client to participate in treatment decisions

A - Determine the client's risk of self-harm Rational A - The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self-harm or suicide. The first action the nurse should take is to determine the client's risk for self-harm to ensure that the client is provided with a safe environment B - The nurse should instill hope for positive outcomes, without providing false reassurance, as part of milieu therapy. However, there is another action that the nurse should take first. C - The nurse should encourage the client to participate in group therapy to assist the client to address social impairments that result from the disorder. However, there is another action that the nurse should take first D - The nurse should encourage the client to participate in treatment decisions as part of milieu therapy. However, there is another action that the nurse should take first.

A nurse is reinforcing teaching with an adolescent client who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A - Eat a diet high in fiber B - Check temperature daily C - Take medication first thing in the morning before eating D - Add extra calories to the diet as between-meal snacks

A - Eat a diet high in fiber Rational A - Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use B - Checking the client's temperature daily is not necessary while taking a TCA C - Taking the medication at bedtime rather than in the morning is appropriate to prevent daytime sleepiness D - Following a well-balanced diet plan, rather than adding extra calories as snacks, will help prevent weight gain, a common adverse effect of TCAs

A nurse in an acute mental health facility is assisting with the admission of a client who has major depressive disorder and anxiety disorder. Which of the following actions is the nurse's priority? A - Placing the client on one-on-one observation B - Assisting the client to preform ADL's C - Encouraging the client to participate in counseling D - Reinforcing teaching with the client about medication adverse effects.

A - Placing the client on one-on-one observation Rational A - The greatest risk for a client who has MDD and anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-on-one observation. B - The client who has MDD can require assistance with ADLs. However, this does not address the greatest risk to the client and is therefore not the propriety intervention. C - The nurse should encourage the client who has MDD to participate in counseling. However, this does not address the greatest risk to the client D - The nurse should reinforce teaching with the client who has MDD about medication adverse effects. However, this does not address the greatest risk to the client

Therapy for a child with autism spectrum disorder involve the following (Select all) A - Positive behavior modification B - Maximize ability to live independently C - Observe communication milestones D- Design strict discipline measures for behavior problems

A - Positive behavior modification B - Maximize ability to live independently C - Observe communication milestones

A nurse is obtaining a health history from the parents of a 12-year-old client who has conduct disorder. Which of the following findings should the nurse expect? (Select all) A - Bullying others B - Threats of suicide C - Law-breaking activities D - Narcissistic behavior E - Flat affect

A, B, & C A - Bullying others B - Threats of suicide C - Law-breaking activities Rational D - Low self-esteem, rather than narcissism, is an expected finding of conduct disorder E - Irritability and temper outbursts, rather than a flat affect, are expected findings of conduct disorder

A nurse is an acute mental health facility is caring for a 35-year-old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? (Select all) A - Age B - Sex C - History of chronic asthma D - Smoking E - Being married

A, B, C & D A - Age B - Sex C - History of chronic asthma D - Smoking Rational E - Depressive disorders are more common in unmarried clients

A nurse working on an acute mental health unit is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all) A - Difficulty concentrating on tasks B - Obsessive need to talk about the traumatic event C - Negative self-image D - Recurring nightmares E - Diminished reflexes

A, C & D A - Difficulty concentrating on tasks C - Negative self-image D - Recurring nightmares Rational B - A client who has PTSD is reluctant to talk about the traumatic even that triggered the disorder E - A client who has PTSD has an increased startle reflex and hypervigilance

A nurse is reinforcing teaching about minimizing anticholinergic effects with a client who has a new prescription for imipramine. Which of the following instructions should the nurse include? (Select all) A - Void just before taking the medication B - Increase the dietary intake of potassium C -Wear sunglasses when outside D - Change positions slowly when getting up E - Chew sugarless gum

A, C & E A - Void just before taking the medication C -Wear sunglasses when outside E - Chew sugarless gum Rational A - Voiding just before taking the medication will help minimize the anticholinergic effects of urinary hesitancy or retention B - The anticholinergic effects of imipramine do not affect the client's potassium levels C - Wearing sunglasses when outside will help minimize the anticholinergic effect of photophobia D - The client should change positions slowly to avoid orthostatic hypotension. However, this is not an anticholinergic effect E - Chewing sugarless gum will help minimize the anticholinergic effect of dry mouth

A nurse is discussing early indications of toxicity with a client who has bipolar disorder and a new prescription for lithium. Which of the following manifestations should the nurse include? (Select all) A - Constipation B- Polyuria C - Rash D - Muscle weakness E - Tinnitus

B & D B- Polyuria D - Muscle weakness Rational A - Diarrhea, rather then constipation, is an early indication of lithium toxicity B - Polyuria is an early indication of lithium toxicity C - A rash is not an indication of lithium toxicity D - Muscle weakness is an early indication of lithium toxicity E - Tinnitus is an indication of severe, rather than early, toxicity.

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make? A - "Why do you think you feel the need to give money away." B - "I am here to care for you and cannot accept your money." C - "I can request that your case manage discuss local charity options with you." D - "You should know that giving away your money is not allowed."

B - "I am here to care for you and cannot accept your money." Rational A - Asking a "why" question is a non-therapeutic form of communication and can promote a defensive client response. B - The statement is matter-of-fact, concise and a therapeutic response to a client who has bipolar disorder C - This statement does not recognize the possibility of poor judgment, which is associated with bipolar disorder D - This statement offers disapproval and can be interpreted by the client as aggressive, which can promote a defense client response.

A nurse is reinforcing teaching with a client who has a new prescription for amitriptyline. Which of the following statements by the client indicates understanding? A - "While taking this medication, I'll need to stay out of the sun to avoid a skin rash." B - "I may feel drowsy for a few weeks after starting this medication." C - "I cannot eat my favorite pizza with pepperoni while taking this medication." D - "This medication will help me lose the weight that I have gained over the last year."

B - "I may feel drowsy for a few weeks after starting this medication." Rational A - Skin rash is associated with SSRIs rather than TCAs like amitriptyline B - Sedation is an adverse effect of amitriptyline during the first few weeks of therapy C - Foods such as pepperoni should be avoided if the client is prescribed an MAOI rather than a TCA D - Weight gain, rather than weight loss, is expected with TCA's

A nurse is caring for a client who has bipolar disorder and a new prescription for lithium. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A - "That is a good choice. Ibuprofen does not interact with lithium." B - "Regular aspirin would be a better choice than ibuprofen." C - "Lithium decreases the effectiveness of ibuprofen." D - "The ibuprofen will make your lithium level fall too low."

B - "Regular aspirin would be a better choice than ibuprofen." Rational A - Ibuprofen in not recommended for clients taking lithium B - Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk of lithium toxicity. C - Lithium does not decrease the effectiveness of ibuprofen. However, concurrent use is not recommended due to the risk of toxicity. D - Ibuprofen increases the risk for a toxic, rather than low, lithium level

A nurse is preparing to assist with the care of a client who has benzodiazepine toxicity due to an overdose. Which of the following actions should the nurse plan to take first? A - Administer flumazenil B - Identify the client's level of orientation C -Infuse IV fluids D - Prepare the client for gastric lavage

B - Identify the client's level of orientation Rational A - Administering flumazenil is an appropriate action. However, it is not the priority when taking the nursing process approach to client care B - When taking the nursing process approach to client care, the initial step is collecting data. Identifying the client's level of orientation is the priority action C - Infusing IV fluids is an appropriate action. However, it is not the priority when taking the nursing process approach to client care D - Gastric lavage is an appropriate action. However, it is not the priority when taking the nursing process approach to client care

A nurse is collecting data from a 4-year-old child to monitor for manifestations of autism spectrum disorder. For which of the following manifestations should the nurse monitor? A - Impulsive behavior B - Repetitive counting C - Destructiveness D - Somatic problems

B - Repetitive counting Rational A - Impulsive behavior is an indication of ADHD rather than autism spectrum disorder B - Repetitive actions and strict routines are an indication of autism spectrum disorder C - Destructiveness is an indication of conduct disorder rather than autism spectrum disorder. D - Somatic problems are an indication of post-traumatic stress disorder rather than autism spectrum disorder.

A nurse is reinforcing teaching with a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (Select all) A - An adverse effect of this medication is CNS depression B - Administer the medication in the morning C - Monitor for weight loss while taking this medication D - Therapeutic effects of this medication will take 1 to 3 weeks to fully develop E - The medication blocks the synaptic reuptake of serotonin in the brain

B, C & E B - Administer the medication in the morning C - Monitor for weight loss while taking this medication E - The medication blocks the synaptic reuptake of serotonin in the brain Rational A - An adverse effect of fluoxetine is CNS stimulation B - Fluoxetine should be administered in the morning due to the potential for insomnia C - Fluoxetine can result in weight loss D- Fluoxetine take 4 weeks to fully develop therapeutic effects E - Fluoxetine works by blocking the synaptic reuptake of serotonin, allowing more serotonin to stay at the junction of the neurons

A nurse is assisting in a serious and prolonged mass casualty incident at an acute care facility. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all) A - Avoid thinking about the incident when it is over B - Take breaks during the incident for food and water C - Debrief with others following the incident D - Hold emotions in check in the days following the incident E - Take advantage of offered counseling

B, C & E B - Take breaks during the incident for food and water C - Debrief with others following the incident E - Take advantage of offered counseling Rational A - Thinking and talking about a traumatic incident can help prevent development of a trauma-related disorder D - Displaying emotions following a traumatic incident can help precent development of a trauma-related disorder

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan? (Select all) A - Provide flexible client behavior expectations B - Offer concise limits C - Establish consistent limits D - Disregard client complaints E - Use a firm approach with communication

B, C, & E B - Offer concise limits C - Establish consistent limits E - Use a firm approach with communication Rational A - The nurse should establish consistent client behavior expectations to decrease the risk of client manipulation D - The nurse should respond to valid client complaints to foster a trusting nurse-client relationship

A nurse is reinforcing teaching about relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include? (Select all) A - Use caffeine in moderation to prevent relapse B - Difficulty sleeping can indicate a relapse C - Begin taking medications as soon as a relapse beings D - Participating in psychotherapy can help prevent a relapse E - Anhedonia is a clinical manifestation of a depressive relapse

B, D & E B - Difficulty sleeping can indicate a relapse D - Participating in psychotherapy can help prevent a relapse E - Anhedonia is a clinical manifestation of a depressive relapse Rational A - The client who has bipolar disorder should avoid the use of caffeine, which can precipitate a relapse C - The client who has bipolar disorder should take prescribed medications to prevent and minimize a relapse

A nurse is collecting data from an adolescent client who has a depressive disorder. Which of the following manifestations should the nurse expect? (Select all) A - Fear of being alone B - Substance use C - Weight gain D - Irritability E - Aggressiveness

B, D & E B - Substance use D - Irritability E - Aggressiveness Rational A - Solitary play or work, rather than the fear of being alone, is an expected finding associated with a depressive disorder C - Loss of appetite and weight loss, not weight gain, are expected findings associated with a depressive disorder.

A nurse is reinforcing teaching with an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? (Select all) A - Somnolence B - Yellowing skin C - Increased appetite D - Fever E - Malaise

B, D & E B - Yellowing skin D - Fever E - Malaise Rational A - Insomnia, rather than somnolence, is an adverse effect that the client should report to the provider B- Yellow skin is a potential indication of hepatotoxicity that the client should report to the provider C - Decreased appetite with resulting weight loss is a potential adverse effect that the client should report to the provider D - Fever is a potential indication of hepatotoxicity that the client should report to the provider E - Malaise is a potential indication of hepatotoxicity that the client should report to the provider

A nurse is reinforcing teaching to a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indications understanding? A - "ECT is the recommend initial treatment for bipolar disorder" B - "ECT is contraindicated for clients who have suicidal ideation." C - "ECT is effective for clients who are experiencing severe mania." D - "ECT is prescribed to prevent relapse of bipolar disorder."

C - "ECT is effective for clients who are experiencing severe mania." Rational A - Pharmacological interventions is the recommended initial treatment for bipolar disorder B - ECT is effective for clients who have bipolar disorder and suicidal ideation C - ECT is appropriate for the treatment of severe mania associated with bipolar disorder D - ECT is prescribed for clients experiencing an acute episode of bipolar disorder rather than for the prevention of relapse

A nurse in an outpatient mental health clinic is reinforcing teaching with a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A - "I can expect my problems with PMDD to be the worst when I'm menstruating." B - "I will use light therapy 30 minutes a day to prevent further recurrence of PMDD C - "I am aware that my PMDD causes me to have rapid mood swings." D - "I should increase my caloric intake with a nutritional supplement when my PMDD is active"

C - "I am aware that my PMDD causes me to have rapid mood swings." Rational A - Clinical findings of PMDD are present during the luteal phase of the menstrual cycle just prior to menses B - Light therapy is a first-line treatment for seasonal affective disorder C - A clinical findings of PMDD is emotional lability. The client can experience rapid changes in mood D - PMDD increases the client's risk for weight gain due to overeating. The client should not increase caloric intake

A nurse is reinforcing teaching with client who is to begin taking fluoxetine for treatment of generalized anxiety disorder. Which of the following client statements indicates understanding of the nurse's instructions? A - "I will take the medication at bedtime." B - "I will follow a low-sodium diet while taking this medication." C - "I will need to discontinue this medication slowly." D - "I will be at risk for weight loss with long-term use of this medication."

C - "I will need to discontinue this medication slowly." Rational A - The client should take fluoxetine in the morning to minimize sleep disturbance B - The client is are risk for hyponatremia while taking fluoxetine C - When discontinuing fluoxetine, the client should tapper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal syndrome D - The client is at risk for weight gain, rather than loss, with long-term use of fluoxetine.

A nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A "Care during the continuation phase focuses on treatment continued manifestations of MDD." B - "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C - "The client is at greatest risk for suicide during the first weeks of an MDD episode." D - "Medication and psychotherapy are most effective during the acute phase of MDD."

C - "The client is at greatest risk for suicide during the first weeks of an MDD episode." Rational A - The focus of the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD B - The maintenance phase of treatment for MDD can last for 1 year or more C - The client is at greatest risk for suicide during the acute phase of MDD D - Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD

A nurse observes a client who has OCD repeatedly applying removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A - Narcissistic behavior B - Fear of rejection from staff C - Attempt to reduce anxiety D - Adverse effect of antidepressant medication

C - Attempt to reduce anxiety Rational A - Clients who have OCD demonstrate receptive behavior but not out of narcissism, which might be associated with personalty disorders. B - Clients who have OCD demonstrate repetitive behavior but not out of fear of rejection, which might be associated with social phobia anxiety disorder. C - Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety D - Clients who have OCD might take an antidepressant to help control repetitive behavior

A nurse is assisting with the admission of a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? A - Wide fluctuations in mood B - Report of a minimum of five clinical findings of depression C - Presence of manifestations for at least 2 years D - Inflated sense of self-esteem

C - Presence of manifestations for at least 2 years Rational A - Wide fluctuations in mood are associated with bipolar disorder B - MDD contains a minimum of five clinical findings of depression C - Manifestations of dysthymic disorder last for at least 2 years in adults. D - A decreased, rather than inflated, sense of self-esteem is associated with dysthymic disorder.

A nurse is reviewing the medical record for a client who has major depressive disorder and a new prescription for bupropion. Which of the following findings is the priority for the nurse to report to the provider? A - The client has a family history of seasonal patten depression B - The client currently smokes 1.5 packs of cigarettes per day C - The client had a motor vehicle crash last year and sustained a head injury D - The client has a BMI of 25 and has gained 10 pounds over the last year.

C - The client had a motor vehicle crash last year and sustained a head injury Rational A - The nurse should report family history information. However, this does not address the greatest risk to the client and is not the priority. B - The nurse should report the client's current smoking status. However, this does not address the greatest risk to the client and is not the priority. C - The greatest risk to the client is development of seizures. Bupropion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This information is the highest priority to report to the provider D - The nurse should report the client's BMI and change in weight. However, this does not address the greatest risk to the client and is not the priority.

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A - The client explains that her body seems to be floating above the ground B - The client has the idea that someone is trying to kill her and steal her money C - The client states that the furniture in the room seems to be small and far away D - The client cannot recall anything that happened during the past 2 weeks

C - The client states that the furniture in the room seems to be small and far away Rational A - Feeling that one's body is floating above the ground is an example of depersonalization, in which the person seems to observe her own body from a distance B - Having the idea that others are trying to hurt or kill her is an example of a paranoid delusion C - Stating that one's surroundings are far away or unreal in some way is an example of derealization D - Being unable to recall any events from the past 2 weeks is an example fo amnesia

A nurse is assisting the parents of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following is an appropriate strategy for the nurse to recommend? (Select all) A - Allow the child to choose consequences for negative behavior B - Use role-playing to act our unacceptable behavior C - Develop a reward system for acceptable behavior D - Encourage the child to participate in school sports E - Be consistent when addressing unacceptable behavior.

C, D & E C - Develop a reward system for acceptable behavior D - Encourage the child to participate in school sports E - Be consistent when addressing unacceptable behavior. Rational A - The parent should set clear limits on unacceptable behavior B - The parents should focus on acceptable behavior and demonstrate this through modeling

A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following actions is the nurse's priority? A - Set consistent limits for expected client behavior B - Administer prescribed medications as scheduled C - Provide step-by-step instructions during hygiene activities D - Monitor for escalating behavior

D - Monitor for escalating behavior Rational A - The nurse should set consistent limits for expected client behavior. However, this does not address the client's priority need for safety and is therefore not the priority action B - The nurse should administer prescribed medication as scheduled. However, this doe snot address the client's propriety need for safety. C - The nurse should provide the client with step-by-step instructions during hygiene activities. However, this does not address the client's propriety need for safety. D - Monitoring for escalating behavior addresses the client's need for safety. Therefore, this is the nurse's priority action

A nurse is reinforcing teaching with a school-age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A - Apply the patch once daily at bedtime B - Place the patch carefully in a trash can after removal C - Apply the transdermal patch to the anterior waist area D - Remove the patch each day after 9 hr

D - Remove the patch each day after 9 hr Rational A - The transdermal patch is applies one daily in the morning B - For safety when discarding the transdermal preparation, the client should fold the patch and flush it down the toilet to prevent others from using it C - The transdermal patch should be applied to a clean, dry area on the hip, and the waist area should be avoided.

A nurse working in a mental health clinic is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for diazepam. Which of the following information should the nurse reinforce? A - Three to six weeks of treatment is required to achieve therapeutic benefit B - Combining alcohol with diazepam will produce a paradoxical response C - Diazepam has a lower risk for dependence than other anti-anxiety medications D - Report confusion as a potential indication of toxicity

D - Report confusion as a potential indication of toxicity Rational A - Buspirone, rather than diazepam, requires 3 to 6 weeks to achieve therapeutic benefit B - Combining alcohol with diazepam can produce CNS and respiratory depression rather than a paradoxical response C - Diazepam is preferably used for short-term treatment because of the increased risk of dependence D - Confusion is a potential indication of diazepam toxicity that the client should report to the provider

A nurse is collecting data from a client who has acute stress disorder (ASD). Which of the following findings should the nurse expect? A - The client remembers many details about the traumatic incident B - The client expresses heightened elation about what is happening C - The client states he first notices manifestations of the disorder 6 weeks after the traumatic incident occurred D - The client expresses a sense of unreality about the traumatic incident

D - The client expresses a sense of unreality about the traumatic incident Rational A - The client who has ASD tens to be unable to remember details about the incident and can block the entire incident form memory B - The client who has ASD reacts to what is happening with negative emotions (anger, guilt, depression, anxiety). Elation can occur in client's who have mania. C - Manifestations of ASD occur immediately to a few days following the event

A nurse is an acute mental health facility is contributing to the plan of care for a client who has dissociative fugue. Which of the following interventions should the nurse include? A - Encourage the client to recognize how stress brings on a personality change in the client B - Repeatedly present the client with information about past events C - Make decisions for the client regarding routine daily activities D - Work with the client on grounding techniques

D - Work with the client on grounding techniques Rational A - The client who has dissociative identity disorder displays multiple personalities, while the client who has dissociative fugue has amnesia regarding her identity and past B - The nurse should avoid flooding the client with information about past events, which can increase the client's level of anxiety C - The nurse should encourage the client to make decisions regarding routine daily activities in order to promote improved self-esteem and decreases the client's feelings of powerlessness D - Grounding techniques (Stomping feet, clapping hands, touching physical objects) are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization

Depressive Spectrum

overwhelming sadness and despair that one feels drained of energy person who is depression may have somatic complains such as headaches, stomachache, dizziness, nausea, indigestion, constipation, and change in sexual responsiveness. Inability to concentrate and indecisiveness