QUIZ 5

A 16-year-old client diagnosed with schizophrenia spectrum disorder experiences command hallucinations to harm others. The client's parents ask a nurse, "Where do the voices come from?" Which is the appropriate nursing response? 1. "Your child has a chemical imbalance of the brain, which leads to altered perceptions." 2. "Your child's hallucinations are caused by medication interactions." 3. "Your child has too little serotonin in the brain, causing delusions and hallucinations." 4. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."

1. "Your child has a chemical imbalance of the brain, which leads to altered perceptions." Rationale: The nurse should explain that a chemical imbalance of the brain leads to altered perceptions. Hallucinations, or false sensory perceptions, may occur in all 5 senses. The client hearing voices is experiencing an auditory behavior

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? (Select all that apply.) 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. Restrict sodium content. 5. Restrict fluids to 1,500 mL per day.

1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. Rationale: The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high because of the narrow margin between therapeutic doses and toxic levels. Fluid or sodium restriction can impact lithium levels. Cognitive Level: Application Integrated Process: Implementation

17. Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.) 1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18. 5. Genetic predisposition is not a reliable diagnostic determinant. Nursing Process: Assessment Client Need: Psychological Integrity

1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms. 2. Children are naturally active, energetic, and spontaneous. Rationale: It is difficult to diagnose a child or adolescent with bipolar disorder, because bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder. Cognitive Level: Application Integrated Process: Assessment

Which of the following components should a nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with schizophrenia spectrum disorder? (Select all that apply.) 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

1. Group therapy 2. Medication management 4. Supportive family therapy 5. Social skills training Rationale: The nurse should recognize that group therapy, medication management, supportive family therapy, and social skills training all play an integral part rehabilitative programs for clients diagnosed with schizophrenia spectrum disorder. Schizophrenia results from various combinations of genetic predispositions, biochemical dysfunctions, physiological factors, and psychological stress. Effective treatment requires a comprehensive, multidisciplinary effort.

The diagnosis of catatonic disorder associated with another medical condition is made when the client's medical history, physical examination, or laboratory findings provide evidence that symptoms are directly attributed to which of the following? (Select all that apply.) 1. Hyperthyroidism 2. Hypothyroidism 3. Hyperadrenalism 4. Hypoadrenalism 5. Hyperaphia

1. Hyperthyroidism 2. Hypothyroidism 3. Hyperadrenalism 4. Hypoadrenalism Rationale: The diagnosis of catatonic disorder associated with another medical condition is made when the symptomatology is evidenced from medical history, physical examination, or laboratory findings to be directly attributable to the physiological consequences of a general medical condition. Types of medical conditions that have been associated with catatonic disorder include metabolic disorders (e.g., hepatic encephalopathy, hypo- and hyperthyroidism, hypo- and hyperadrenalism, and vitamin B12 deficiency) and neurological conditions (e.g., epilepsy, tumors, cerebrovascular disease, head trauma, and encephalitis). Hyperaphia is an excessive sensitivity to touch.

After taking chlorpromazine (Thorazine) for 1 month, a client presents to an ED with severe muscle rigidity, tachycardia, and a temperature of 105oF (40.5°C). Which medical diagnosis and treatment should a nurse anticipate when planning care for this client? 1. Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium) 2. Neuroleptic malignant syndrome treated by increasing Thorazine dosage and administering an antianxiety medication 3. Dystonia treated by administering trihexyphenidyl (Artane) 4. Dystonia treated by administering bromocriptine (Parlodel)

1. Neuroleptic malignant syndrome treated by discontinuing Thorazine and administering dantrolene (Dantrium) Rationale: The nurse should expect that an ED physician would diagnose the client with NMS and treat the client by discontinuing chlorpromazine and administering dantrolene. NMS is a potentially fatal condition characterized by rigidity, fever, altered consciousness, and autonomic instability. The use of typical antipsychotics is largely being replaced by atypical antipsychotics because they have fewer side effects and present a lower risk

A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate total parenteral nutrition to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

1. Provide client with high-calorie finger foods throughout the day. Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lb by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals. Cognitive Level: Application Integrated Process: Implementation

A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

1. Risk for suicide R/T hopelessness Rationale: The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt. Cognitive Level: Analysis Integrated Process: Diagnosis

A nurse is administering risperidone (Risperdal) to a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would most likely decrease because of the therapeutic effect of this medication? (Select all that apply.) 1. Somatic delusions 2. Social isolation 3. Gustatory hallucinations 4. Flat affect 5. Clang associations

1. Somatic delusions 3. Gustatory hallucinations 5. Clang associations Rationale: The nurse should expect that risperidone would be effective treatment for the positive symptoms of somatic delusions, gustatory hallucinations, and clang associations. Risperidone is an atypical antipsychotic that has been effective in the treatment of the positive symptoms of schizophrenia and in maintenance therapy to prevent exacerbation of schizophrenic symptoms.

A client diagnosed with schizophrenia spectrum disorder is prescribed clozapine (Clozaril). Which client symptoms, related to the side effects of this medication, should prompt a nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention

1. Sore throat, fever, and malaise Rationale: The nurse should intervene immediately if the client experiences signs of infectious process, such as sore throat, fever, and malaise, when taking the atypical antipsychotic drug clozapine. Clozapine can have serious side effects of agranulocytosis, in which a potentially fatal drop in WBC can occur, leading to infection

A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit R/T bipolar disorder AEB concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss Rationale: The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Because of the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health. Cognitive Level: Analysis Integrated Process: Diagnosis

A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate? 1. Increase the dosage of fluoxetine. 2. Discontinue the fluoxetine and rethink the client's diagnosis. 3. Order benztropine (Cogentin) to address extrapyramidal symptoms. 4. Order olanzapine (Zyprexa) to address altered thoughts.

2. Discontinue the fluoxetine and rethink the client's diagnosis. Rationale: A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis. Cognitive Level: Analysis Integrated Process: Assessment

A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? 1. Assess for medication nonadherance. 2. Note escalating behaviors and intervene immediately. 3. Interpret attempts at communication. 4. Assess triggers for bizarre, inappropriate behaviors.

2. Note escalating behaviors and intervene immediately. Rationale: The nurse should note escalating behaviors and intervene immediately, to maintain this client's safety. Early intervention may prevent an aggressive response and keep the client and others safe

A nurse is caring for a client who is experiencing a flat affect, paranoid delusions, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? 1. Paranoid delusions, anhedonia, and anergia are positive symptoms of schizophrenia. 2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. 3. Paranoid delusions, anergia, and echolalia are negative symptoms of schizophrenia. 4. Paranoid delusions, flat affect, and anhedonia are negative symptoms of schizophrenia.

2. Paranoid delusions, neologisms, and echolalia are positive symptoms of schizophrenia. Rationale: The nurse should recognize the positive symptoms of schizophrenia include, but are not limited to, paranoid delusions, neologisms, and echolalia. The negative symptoms include flat affect, anhedonia, and anergia. Positive symptoms reflect an excess or distortion of normal functions. Negative symptoms reflect a diminution or loss of normal functions

A nurse prepares to assess a client using the Abnormal Involuntary Movement Scale (AIMS). Which side effect of antipsychotic medications led to the use of this assessment tool? 1. Dystonia 2. Tardive dyskinesia 3. Akinesia 4. Akathisia

2. Tardive dyskinesia Rationale: The AIMS is a rating scale that was developed in the 70s by the National Institute of Mental Health to measure involuntary movements associated with tardive dyskinesia

A client has been assigned an admission diagnosis of brief psychotic disorder. Which assessment information would alert the nurse to question this diagnosis? 1. The client has experienced impaired reality testing for a 24-hour period. 2. The client has experienced auditory hallucinations for the past 3 hours. 3. The client has experienced bizarre behavior for 1 day. 4. The client has experienced confusion for 3 weeks.

2. The client has experienced auditory hallucinations for the past 3 hours. Rationale: This disorder is identified by the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor; these symptoms last at least one day but less than one month

A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

2. Valproic acid (Depakote) Rationale: The nurse should anticipate that the physician may prescribe valproic acid in order to increase this client's medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss. Cognitive Level: Application Integrated Process: Planning

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia spectrum disorder, tells them that voices command him to harm others. Which is the appropriate nursing response? 1. "Tell him to stop discussing the voices." 2. "Ignore what he is saying, while attempting to discover the underlying cause." 3. "Focus on the feelings generated by the hallucinations and present reality." 4. "Present objective evidence that the voices are not real."

3. "Focus on the feelings generated by the hallucinations and present reality." Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality; the parents should accept that their child is experiencing the hallucination but should not reinforce this unreal sensory perception

An aging client diagnosed with schizophrenia spectrum disorder takes an antipsychotic and a beta-adrenergic blocking agent for hypertension. Understanding the combined side effects of these drugs, which statement by a nurse is most appropriate? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

3. "Rise slowly when you change position from lying to sitting or sitting to standing." Rationale: The most appropriate statement by the nurse is to instruct the client to rise slowly when changing positions. Antipsychotic meds and beta blockers cause a decrease in BP. When given in combination, the additive effect of these drugs places the client at risk for developing orthostatic hypotension

A client diagnosed with schizophrenia spectrum disorder states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing response? 1. "Did you take your medicine this morning?" 2. "You are not going to hell. You are a good person." 3. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." 4. "The devil only talks to people who are receptive to his influence."

3. "The voices must sound scary, but the devil is not talking to you. This is part of your illness." Rationale: The most appropriate nursing response is to reassure the client while not reinforcing the hallucination. Reminding the client that the voices are a part of the illness is a way to help the client accept that hallucinations are not real. It is also important for the nurse to connect with the client's fears/inner feelings

A client began taking lithium carbonate (Lithobid) for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common, but troubling, side effect." 4. "Weight gain only occurs during the first month of treatment with this drug."

3. "Weight gain is a common, but troubling, side effect." Rationale: The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication. Cognitive Level: Application Integrated Process: Implementation

. A nurse is assessing a client diagnosed with substance induced psychotic disorder (SIPD). What would differentiate this client's symptoms from the symptoms of a client diagnosed with brief psychotic disorder (BPD)? 1. Clients diagnosed with SIPD experience delusions, whereas clients diagnosed with BPD do not. 2. Clients diagnosed with BPD experience hallucinations, whereas clients diagnosed with SIPD do not. 3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features. 4. Catatonic features may be associated with BPD, whereas SIPD has no catatonic features.

3. Catatonic features may be associated with SIPD, whereas BPD has no catatonic features. Rationale: The diagnosis of SIPD is made when symptoms are directly attributable to substance intoxication or withdrawal. The symptoms are more excessive and more sever than those usually associated with the intoxication/withdrawal syndrome. Hallucinations and delusions are associated with both SIPD and BPD. Catatonic features may be associated with SIPD, where as BPD has no catatonic features

A paranoid client diagnosed with schizophrenia spectrum disorder states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? 1. Magical thinking; administer an antipsychotic medication. 2. Persecutory delusions; orient the client to reality. 3. Command hallucinations; warn the psychiatrist. 4. Altered thought processes; call an emergency treatment team meeting.

3. Command hallucinations; warn the psychiatrist. Rationale: The nurse should determine that the client is exhibiting command hallucinations. The nurse's legal responsibility is to warn the psychiatrist of the potential for harm. Clients demonstrating a risk for violence could potentially be physically, emotionally, and/or sexually harmful to others or to self

12. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode? 1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania. 2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania. 3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. 4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania. Rationale: Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic. Cognitive Level: Analysis Integrated Process: Assessment

A client is diagnosed with schizophrenia spectrum disorder. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? 1. Tactile hallucinations 2. Tardive dyskinesia 3. Restlessness and muscle rigidity 4. Reports of hearing disturbing voices

3. Restlessness and muscle rigidity Rationale: The symptom of tactile hallucinations and reports of hearing disturbing voices would be addressed by an antipsychotic medication such as haloperidol. Tardive dyskinesia, a potentially irreversible condition, would warrant the discontinuation of an antipsychotic med such as haloperidol. An anticholinergic med such as benzotropine would be used to treat the EPS of restless and muscle rigidity

A client diagnosed with schizophrenia spectrum disorder tells a nurse about voices commanding him to kill the president. Which is the priority nursing diagnosis for this client? 1. Disturbed sensory perception 2. Altered thought processes 3. Risk for violence: directed toward others 4. Risk for injury

3. Risk for violence: directed toward others Rationale: The nurse should prioritize the diagnosis risk for violence: directed toward others. A client who hears voices commanding him to kill someone is at risk for other-directed violence. Other risk factors for violence include aggressive body language, verbal aggression, catatonic excitement, and rage reactions

A client diagnosed with schizophrenia spectrum disorder takes an antipsychotic agent daily. Which assessment finding should a nurse prioritize? 1. Respirations of 22 beats/minute 2. Weight gain of 8 pounds in 2 months 3. Temperature of 104°F (40°C) 4. Excessive salivation

3. Temperature of 104°F (40°C) Rationale: When assessing a client diagnosed with schizophrenia spectrum disorder who takes an antipsychotic agent daily, the nurse should immediately address a temperature of 104. Temps this high may indicate NMS, a life threatening side effect of antipsychotic medications

A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

4. "Agitated and pacing. Exhibiting grandiosity. Mood labile." Rationale: The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one's abilities are better than everyone else's. Cognitive Level: Application Integrated Process: Evaluation

A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients can't sleep." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications."

4. "Treatment is compromised when clients choose not to take their medications." Rationale: The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped. Cognitive Level: Application Integrated Process: Evaluation

A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing response? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa increases the effectiveness of the immune system." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

4. "Zyprexa calms hyperactivity until the Eskalith takes effect." Rationale: The nurse should explain to the client's spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder. Cognitive Level: Application Integrated Process: Implementation

A nurse is assessing a client diagnosed with schizophrenia spectrum disorder. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" The nurse is assessing which potential symptom of this disorder? 1. Thought insertion 2. Paranoid delusions 3. Magical thinking 4. Delusions of reference

4. Delusions of reference Rationale: The nurse is assessing for the potential symptom of delusions of reference. A client that believes he or she receives messages through the radio is experiencing delusions of reference. These delusions involve the client interpreting events within the environment as being directed toward him/herself

Which nursing intervention would be most appropriate when caring for an acutely agitated paranoid client diagnosed with schizophrenia spectrum disorder? 1. Provide neon lights and soft music. 2. Maintain continual eye contact throughout the interview. 3. Use therapeutic touch to increase trust and rapport. 4. Provide personal space to respect the client's boundaries.

4. Provide personal space to respect the client's boundaries. Rationale: The most appropriate nursing intervention is to provide personal space to respect the client's boundaries. Providing personal space may serve to reduce anxiety and thus reduce the client's risk for violence

16. A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.) 1. Symptoms lasting for a minimum of two years 2. Numerous periods with manic symptoms 3. Possible comorbid diagnosis of a delusional disorder 4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode

4. Symptoms cause clinically significant impairment in important areas of functioning 5. Depressive symptoms that do not meet the criteria for major depressive episode Rationale: The following are selected criteria for the diagnosis of cyclothymic disorder. For at least one year in children and adolescents there have been numerous periods with hypomanic, not manic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Cognitive Level: Application Integrated Process: Implementation

A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101F (38C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? 1. Symptoms indicate consumption of foods high in tyramine. 2. Symptoms indicate lithium carbonate discontinuation syndrome. 3. Symptoms indicate the development of lithium carbonate tolerance. 4. Symptoms indicate lithium carbonate toxicity.

4. Symptoms indicate lithium carbonate toxicity. Rationale: The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly with maintenance therapy to ensure proper dosage. Cognitive Level: Application Integrated Process: Evaluation

A 60-year-old client diagnosed with schizophrenia spectrum disorder presents in an ED with uncontrollable tongue movements, stiff neck, and difficulty swallowing. Which medical diagnosis and treatment should a nurse anticipate when planning care for this client? 1. Neuroleptic malignant syndrome treated by discontinuing antipsychotic medications 2. Agranulocytosis treated by administration of clozapine (Clozaril) 3. Extrapyramidal symptoms treated by administration of benztropine (Cogentin) 4. Tardive dyskinesia treated by discontinuing antipsychotic medications

4. Tardive dyskinesia treated by discontinuing antipsychotic medications Rationale: The nurse should expect that an ED physician would diagnose the client with tardive dyskinesia and discontinue antipsychotic medications. Tardive dyskinesia is a condition of abnormal involuntary movements of the mouth, tongue, trunk, and extremities that can be a side effect of typical antipsychotic medications

During an admission assessment, a nurse assesses that a client diagnosed with schizophrenia spectrum disorder has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication would be contraindicated? 1. Haloperidol (Haldol), because it is used only in older patients 2. Clozapine (Clozaril), because it is incompatible with desipramine 3. Risperidone (Risperdal), because it exacerbates symptoms of depression 4. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines

4. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines Rationale: The nurse should know that thioridazine would be contraindicated because of cross-sensitivity among phenothiazines. Prochlorperazine and thioridazine are both classified as phenothiazines

3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit? Client Outcomes: 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours a night A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3

C. 3, 1, 4, 2 Rationale: The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's safety and physical health as most important. Cognitive Level: Analysis Integrated Process: Planning

__________ can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

MANIA

___________ is defined as a pervasive and sustained emotion that may have a major influence on a person's perception of the world.

MOOD

Nursing Diagnosis: Risk for __________________ related to - Manic excitement - Delusional thinking - Hallucinations - Impulsivity

Nursing Diagnosis: Risk for VIOLENCE SELF OR OTHER DIRECTED related to - Manic excitement - Delusional thinking - Hallucinations - Impulsivity

Predisposing Factors: Psychosocial theories Credibility of psychosocial theories has decreased/stabilized/increased (pick one) in recent years

Predisposing Factors: Psychosocial theories Credibility of psychosocial theories has DECLINED in recent years

Psychopharmacology: For depressive phase Why should you use antidepressants with care?

Psychopharmacology: For depressive phase Use antidepressants with care (may trigger mania)

The below are all examples of __________ lithium carbonate, clonazepam, carbamazepine, valproic acid, lamotrigine, gabapentin, topiramate, oxcarbazepine, verapamil, antipsychotics

Psychopharmacology: MOOD-STABILIZING AGENTS Examples: lithium carbonate, clonazepam, carbamazepine, valproic acid, lamotrigine, gabapentin, topiramate, oxcarbazepine, verapamil, antipsychotics

________________ (Mood-stabilizing agents) May modulate the effects of certain neurotransmitters, such as norepinephrine, serotonin, dopamine, glutamate, and GABA, thereby stabilizing symptoms associated with bipolar disorder.

Psychopharmacology: Mood-stabilizing agents Action - Lithium --- May modulate the effects of certain neurotransmitters, such as norepinephrine, serotonin, dopamine, glutamate, and GABA, thereby stabilizing symptoms associated with bipolar disorder.

Psychopharmacology: Mood-stabilizing agents What do we use mood-stabilizing agents for?

Psychopharmacology: Mood-stabilizing agents Indications: prevention and treatment of manic episodes associated with bipolar disorder

Psychopharmacology: Side effects Lithium toxicity - Ensure that client consumes adequate ______________ &______________

Psychopharmacology: Side effects Lithium toxicity - Ensure that client consumes adequate sodium and fluid in diet

Psychopharmacology: Side effects Lithium toxicity - Therapeutic range --- 1.0 to 1.5 mEq/L (acute mania) --- 0.6 to 1.2 mEq/L (maintenance)

Psychopharmacology: Side effects Lithium toxicity - Therapeutic range --- 1.0 to 1.5 mEq/L (______________) --- 0.6 to 1.2 mEq/L (______________)

Psychopharmacology: Side effects Side effects of _____________ - Drowsiness, dizziness, headache - Dry mouth; thirst; GI upset; nausea/vomiting - Fine hand tremors

Psychopharmacology: Side effects Monitor for side effects of lithium - Drowsiness, dizziness, headache - Dry mouth; thirst; GI upset; nausea/vomiting - Fine hand tremors

Psychopharmacology: Side effects Additional side effects of lithium - H_ _ _ _ _ _ _ _ _ _; A_ _ _ _ _ _ _ _ _ _, P _ _ _ _ _ irregularities - P_ _ _ _ _ _ _; dehydration - Weight _ _ _ _ - Potential for _ _ _ _ _ _ _ _

Psychopharmacology: Side effects Monitor for side effects of lithium - Hypotension; arrhythmias, pulse irregularities - Polyuria; dehydration - Weight gain - Potential for toxicity

Psychopharmacology: The following are used for _______________ - Lithium carbonate - Anticonvulsants - Verapamil - Antipsychotics

Psychopharmacology: The following are used for _______________ - Lithium carbonate - Anticonvulsants - Verapamil - Antipsychotics

The margin between the therapeutic and toxic levels of l_ _ _ _ _ _ c_ _ _ _ _ _ _ _ is very narrow. The usual ranges of therapeutic serum concentrations are as follows ■ For a_ _ _ _ m_ _ _ _: 1.0 to 1.5 ___/_ ■ For m_ _ _ _ _ _ _ _ _ _: 0.6 to 1.2 ___/_

The margin between the therapeutic and toxic levels of lithium carbonate is very narrow. The usual ranges of therapeutic serum concentrations are as follows ■ For acute mania: 1.0 to 1.5 mEq/L ■ For maintenance: 0.6 to 1.2 mEq/L

Types of Bipolar Disorders: _______________________ Characterized by bouts of major depression with episodic occurrence of hypomania

Types of Bipolar Disorders: BIPOLAR II DISORDER Characterized by bouts of major depression with episodic occurrence of hypomania

Types of Bipolar Disorders: _________________________ Has never met criteria for full manic episode

Types of Bipolar Disorders: BIPOLAR II DISORDER Has never met criteria for full manic episode

Types of Bipolar Disorders: _________________________ Chronic mood disturbance

Types of Bipolar Disorders: CYCLOTHYMIC DISORDER Chronic mood disturbance

Types of Bipolar Disorders: ___________________________ At least 2-year duration

Types of Bipolar Disorders: Cyclothymic Disorder At least 2-year duration

Types of Bipolar Disorders: ___________________________ Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either Bipolar I or II disorder

Types of Bipolar Disorders: Cyclothymic Disorder Numerous episodes of hypomania and depressed mood of insufficient severity to meet the criteria for either Bipolar I or II disorder

Types of Bipolar Disorders: ______________________________ A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication or other treatment).

Types of Bipolar Disorders: Substance-Induced Bipolar Disorder A disturbance of mood (depression or mania) that is considered to be the direct result of the physiological effects of a substance (e.g., ingestion of or withdrawal from a drug of abuse or a medication or other treatment).

1. Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is a. imbalanced nutrition: less than body requirements related to not eating. b. risk for injury related to hyperactivity. c. disturbed sleep pattern related to agitation. d. ineffective coping related to denial of depression.

b. risk for injury related to hyperactivity.

10. A child with bipolar disorder also has attention-deficit/hyperactivity disorder (ADHD). How would these comorbid conditions most likely be treated? a. No medication would be given for either condition. b. Medication would be given for both conditions simultaneously. c. The bipolar condition would be stabilized first before medication for the ADHD would be given. d. The ADHD would be treated before consideration of the bipolar disorder.

c. The bipolar condition would be stabilized first before medication for the ADHD would be given.

2. Margaret, age 68, is diagnosed with Bipolar I Disorder, Current episode manic. She is extremely hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to a. sit with her during meals to ensure that she eats everything on her tray. b. have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. c. provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." d. tell Margaret that she will be on room restriction until she starts gaining weight.

c. provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run."

6. The most common comorbid condition in children with bipolar disorder is a. schizophrenia. b. substance disorder. c. oppositional defiant disorder. d. attention-deficit/hyperactivity disorder.

d. attention-deficit/hyperactivity disorder.

A nursing instructor is teaching about donepezil (Aricept). A student asks, "How does this work? Will this cure Alzheimer's disease (AD)?" Which is the appropriate instructor reply? A. "This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD." B. "This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease." C. "This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD." D. "This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease."

ANS: A The most appropriate response by the instructor is to explain that donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of AD. KEY: Cognitive Level: Analysis | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family, who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential

In assessing a client with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

ANS: B If large doses of a central nervous system (CNS) depressant (such as Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

ANS: B Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client with a history of insomnia has been taking chlordiazepoxide (Librium), 15 mg, at night for the past year. The client currently reports that this dose is no longer helping him fall asleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with neurocognitive disorder due to Alzheimer's disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis? A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance

ANS: C The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Reduction of Risk Potential

A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the client's safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.

ANS: D Forgetfulness is an early symptom of dementia that would alert the nurse to question the client's safety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease. The cause of vascular dementia is related to an interruption of blood flow to the brain. High blood pressure and hypertension are significant factors in the etiology. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "Nothing will help me feel better."

ANS: D Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate

ANS: D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur for as long as 2 weeks after stopping the drug."

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

3. What is the difference between cyclothymic disorder and bipolar disorder? The difference lies in the i_ _ _ _ _ _ _ _: People with bipolar disorder will experience _____ depression and clinically diagnosed _____, while patients with cyclothymia will experience ___-grade depression and mild _____, also known as h_ _ _ _ _ _ _ _.

The difference lies in the intensity: People with bipolar disorder will experience MAJOR depression and clinically diagnosed MANIA, while patients with cyclothymia will experience LOW-grade depression and mild MANIA, also known as hypomania.

3. The physician orders lithium carbonate 600 mg tid for a newly diagnosed client with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. Therapeutic range for acute mania is a. 1.0 to 1.5 mEq/L. b. 10 to 15 mEq/L. c. 0.5 to 1.0 mEq/L. d. 5 to 10 mEq/L.

a. 1.0 to 1.5 mEq/L.

__________ or _______________ may or may not be part of clinical picture

DELUSIONS or HALLUCINATIONS may or may not be part of clinical picture

Degree of Severity Stage I—_____________: symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization - Cheerful mood - Rapid flow of ideas; heightened perception - Increased motor activity

Degree of Severity Stage I—HYPOMANIA: symptoms not sufficiently severe to cause marked impairment in social or occupational functioning or to require hospitalization - Cheerful mood - Rapid flow of ideas; heightened perception - Increased motor activity

Laboratory results reveal decreased levels of prolactin in a client diagnosed with schizophrenia spectrum disorder. Which of the following client symptoms would a nurse expect to observe during assessment? (Select all that apply.) 1. Apathy 2. Social withdrawal 3. Anhedonia 4. Auditory hallucinations 5. Delusions

1. Apathy 2. Social withdrawal 3. Anhedonia Rationale: The nurse should expect that a client with decreased levels of prolactin may experience apathy, social withdrawal, and anhedonia. Decreased levels of prolactin can cause depression, which could result in these symptoms.

Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder? 1. Establishing personal contact with family members 2. Being reliable, honest, and consistent during interactions 3. Sharing limited personal information 4. Sitting close to the client to establish rapport

2. Being reliable, honest, and consistent during interactions Rationale: The nurse can enhance the establishment of a trusting relationship with a client diagnosed with schizophrenia spectrum disorder by being reliable, honest, and consistent during interactions. The nurse should also convey acceptance of the client's needs and maintain a calm attitude when dealing with agitated behavior

Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder? 1. Medication adherence 2. Empowerment of the consumer 3. Total absence of symptoms 4. Improved psychosocial relationships

2. Empowerment of the consumer Rationale: The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential. Cognitive Level: Application Integrated Process: Assessment

A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

ANS: C A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

ANS: C Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |Client Need: Psychosocial Integrity

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)? A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity

ANS: C The nurse should identify that attention and concentration are impaired in neurocognitive disorder and not in pseudodementia (depression). KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

During group therapy, a client diagnosed with alcohol use disorder states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol use disorder. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimer's disease. What should cause the nurse to question this diagnosis? A. Neurocognitive disorder does not typically occur in African American clients. B. The symptoms presented are more indicative of Parkinsonism. C. Neurocognitive disorder does not develop suddenly. D. There has been no T3 or T4 level evaluation ordered.

ANS: C The nurse should know that neurocognitive disorder (NCD) does not develop suddenly and should question this diagnosis. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed. The disease is generally progressive and debilitating. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. "I am sad most of the time and I've felt this way for the last several years." B. "I find myself preoccupied with death." C. "Sometimes I hear voices telling me to kill myself." D. "I'm afraid to leave the house."

ANS: A Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition? A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism

ANS: C The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). In NCD, impairment is evident in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client diagnosed with chronic alcohol use disorder is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.

ANS: A The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. "Taking multiple medications may lead to adverse interactions or toxicity." B. "Age-related cognitive changes may lead to alterations in mental status." C. "Lack of rigorous exercise may lead to decreased cerebral blood flow." D. "Decreased social interaction may lead to profound isolation and psychosis."

ANS: A The nurse should identify that taking multiple medications may lead to adverse reactions or toxicity and put an older adult at risk for the development of delirium. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

ANS: A The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread." KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

ANS: B A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient drug rehabilitation program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in the 12-step model for treatment is for the client to admit powerlessness over the substance. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. "I cannot drink any alcohol with this medication." B. "It is going to take 2 to 3 weeks in order for me to begin to feel better." C. "This drug causes physical dependence, and I need to strictly follow doctor's orders." D. "I can't take this medication with food. It needs to be taken on an empty stomach."

ANS: B BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A newly admitted client diagnosed with major depressive disorder states, "I have never considered suicide." Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. "There is nothing to worry about. We will handle it together." B. "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all your options prior to taking this action."

ANS: B By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

ANS: B Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

ANS: B Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this client's assessment data, which diagnosis would the nurse expect the physician to assign? A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimer's disease

ANS: B The nurse should expect that this client would be diagnosed with vascular neurocognitive disorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abrupt onset. This disease often occurs in a fluctuating pattern of progression. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepam (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

ANS: D The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

ANS: D The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which client statement indicates a knowledge deficit related to substance use? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society." B. "Tolerance to heroin develops quickly." C. "Flashbacks from LSD use may reoccur spontaneously." D. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: D The nurse should determine that the client has a knowledge deficit related to substance use when the client compares marijuana to smoking cigarettes and claims it to be harmless. Both of these substances have potentially harmful effects. Cannabis is the second most widely abused drug in the United States. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance

An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft)

ANS: D The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the client's social functioning and concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with neurocognitive disorder due to Alzheimer's disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

ANS: D The nurse should recognize that this client is in the late stage of Alzheimer's disease. The late stage is characterized by a severe cognitive decline. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

ANS: D The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with neurocognitive disorder due to Alzheimer's disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the client's room with name and number D. Assist with bathing and toileting

ANS: D The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

A nurse is interviewing a client in an outpatient drug treatment clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

True/False This is an appropriately written outcome measure. -States that they are able to control their behavior now that the voices are no longer telling them what to do.

True/False This is an appropriately written outcome measure. False an appropriate outcome would be: - Accepts responsibility for own behaviors

Types of Bipolar Disorders: ________________________ Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms

Types of Bipolar Disorders: BIPOLAR I DISORDER Client is experiencing, or has experienced, a full syndrome of manic or mixed symptoms

Types of Bipolar Disorders: ________________________ May also have experienced episodes of depression

Types of Bipolar Disorders: BIPOLAR I DISORDER May also have experienced episodes of depression

Types of Bipolar Disorders: ______________________________ Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition.

Types of Bipolar Disorders: Bipolar Disorder Associated With Another Medical Condition Characterized by an abnormally and persistently elevated, expansive, or irritable mood and excessive activity or energy that is judged to be the result of direct physiological effects of another medical condition.

Degree of Severity Stage III—_________________: a grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare since the advent of antipsychotic medication. - Labile mood; panic anxiety - Clouding of consciousness; disorientation - Frenzied psychomotor activity - Exhaustion and possibly death without intervention

Degree of Severity Stage III—DELIRIOUS MANIA: a grave form of the disorder characterized by an intensification of the symptoms associated with acute mania. The condition is rare since the advent of antipsychotic medication. - Labile mood; panic anxiety - Clouding of consciousness; disorientation - Frenzied psychomotor activity - Exhaustion and possibly death without intervention

Degree of Severity Stage II—______________: marked impairment in functioning; usually requires hospitalization - Elation and euphoria; a continuous "high" - Flight of ideas; accelerated, pressured speech - Hallucinations and delusions - Excessive motor activity - Social and sexual inhibition - Little need for sleep

Degree of Severity Stage II—ACUTE MANIA: marked impairment in functioning; usually requires hospitalization - Elation and euphoria; a continuous "high" - Flight of ideas; accelerated, pressured speech - Hallucinations and delusions - Excessive motor activity - Social and sexual inhibition - Little need for sleep

7. A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia

b. Tinnitus, severe diarrhea, ataxia

5. Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the ED by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of a a. delusion of grandeur. b. delusion of persecution. c. delusion of reference. d. delusion of control or influence.

b. delusion of persecution.

8. A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell the client she cannot wear this outfit while she is in the hospital. b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit she must remain in her room.

c. Quietly walk with her back to her room and help her change into something more appropriate.

9. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 1. "Risky Activity" tool 2. "FIND" tool 3. "Consensus Committee" tool 4. "Monotherapy" tool

2. "FIND" tool Rationale: The nurse should use the "FIND" tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children. Cognitive Level: Application Integrated Process: Assessment

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should be included in the nurse's teaching? 1. The side effects of medications 2. Deep breathing techniques to decrease stress 3. How to make eye contact when communicating 4. How to be a leader

3. How to make eye contact when communicating Rationale: The nurse should plan to teach the client how to make eye contact when communicating. Social skills, such as making eye contact, can assist clients to communicate needs and to establish relationships

A somewhat milder form of mania is called ____________

A somewhat milder form of mania is called HYPOMANIA

___________is described as the emotional reaction associated with an experience.

AFFECT

A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills

ANS: A A client raised in an environment that reinforces one's inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

ANS: A A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Psychosocial Integrity

A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL

ANS: A According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the client's laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal."

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with depression and substance use disorder has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. The individual is experiencing psychological addiction. B. The individual is experiencing physical addiction. C. The individual is experiencing substance addiction. D. The individual is experiencing social addiction.

ANS: A The nurse should use the term "psychological addiction" to best describe this client's situation. A client is considered to be psychologically addicted to a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity: Reduction of Risk Potential

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to a nurse that discharge teaching about this medication has been successful? Select all that apply. A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."

ANS: A, B, C, E The nurse should evaluate that teaching has been successful when the client states that phenelzine (Nardil) should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can have negative interactions with other medications. The client needs to tell other physicians about taking MAOIs because of the risk of drug interactions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which of the following nursing statements exemplify important insights that will promote effective intervention with clients diagnosed with substance use disorders? Select all that apply. A. "I am easily manipulated and need to work on this prior to caring for these clients." B. "Because of my father's alcoholism, I need to examine my attitude toward these clients." C. "Drinking is legal, so the diagnosis of substance use disorder is an infringement on client rights." D. "Opiate addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training." E. "I can fix clients diagnosed with substance use disorders as long as I truly care about them."

ANS: A, B, D The nurse should examine personal bias and preconceived negative attitudes prior to caring for clients diagnosed with substance-abuse disorders. A deficit in this area may affect the nurse's ability to establish therapeutic relationships with these clients. A nurse who adopts the attitude that he or she can "fix" another person may be struggling with codependency issues. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed? Select all that apply. A. "A diet rich in protein will promote hepatic healing." B. "This condition leads to a rise in serum ammonia, resulting in impaired mental functioning." C. "In this condition, blood accumulates in the abdominal cavity." D. "Neomycin and lactulose are used in the treatment of this condition." E. "This condition is caused by the inability of the liver to convert ammonia to urea."

ANS: A, C The nursing instructor should understand that further teaching is needed if the nursing student states that a diet rich in protein will promote hepatic healing or that this condition causes blood to accumulate in the abdominal cavity (ascites), because these are incorrect statements. The treatment of hepatic encephalopathy requires abstention from alcohol, temporary elimination of protein from the diet, and reduction of intestinal ammonia by means of neomycin or lactulose. This condition occurs in response to the inability of the liver to convert ammonia to urea for excretion. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity

A 20-year-old female has a diagnosis of premenstrual dysphoric disorder. Which of the following should a nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months C. Mood swings occur the week before onset of menses D. Patient reports subjective difficulty concentrating E. Patient manifests pressured speech when communicating

ANS: A, C, D Diagnostic criteria for a premenstrual dysphoric disorder include that symptoms must be associated with significant distress, occur in the week before onset of menses, and improve or disappear in the week post-menses KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."

ANS: B A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients diagnosed with amnesic disorders? A. Neurocognitive disorders involve disorientation that develops suddenly, whereas amnestic disorders develop more slowly. B. Neurocognitive disorders involve impairment of abstract thinking and judgment, whereas amnestic disorders do not. C. Neurocognitive disorders include the symptom of confabulation, whereas amnestic disorders do not. D. Both neurocognitive disorders and profound amnesia typically share the symptom of disorientation to place, time, and self.

ANS: B Neurocognitive disorders involve impairment of abstract thinking and judgment. Amnestic disorders are characterized by an inability to learn new information and to recall previously learned information, with no impairment in higher cortical functioning or personality change. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, "I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."

ANS: B Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

ANS: B The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance use disorder? A. Narcotic pain medication is contraindicated for all clients with active substance-use problems. B. Clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance use disorder. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance use disorder because clients who are regularly using alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessens the client's response to another drug. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, "I heard about something called a monoamine oxidase inhibitor (MAOI). Can't my doctor add that to my medications?" Which is an appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."

ANS: B The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of "dread." KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediately report to the ED physician? A. Antecubital bruising B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors

ANS: B, C, D The nurse should identify drastic temperature and barometric pressure changes, increased levels of melatonin, and/or variations in serotonergic functioning as contributing to the etiology of the client's symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is in the late stage of Alzheimer's disease. To address the client's symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.

ANS: C KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Basic Care and Comfort

A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

ANS: C A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimer's disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

At what time during a 24-hour period should a nurse expect clients with Alzheimer's disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications

ANS: C The nurse should determine that clients with Alzheimer's disease exhibit more pronounced symptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the late afternoon and evening. KEY: Cognitive Level: Comprehension| Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this client's symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

ANS: C Learning theory describes a model of "learned helplessness" in which multiple life failures cause the client to abandon future attempts to succeed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client, using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine whether the individual has a problem with alcohol. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "I just need to work harder to get him there on time." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?"

ANS: C The appropriate nursing response is to use confrontation with caring. In Stage One (The Survival Stage) of recovery from codependency, the codependent person must begin to let go of the denial that problems exist or that his or her personal capabilities are unlimited. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A client diagnosed with alcohol use disorder joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the client's behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

ANS: C The initial nursing action is to assess environmental triggers and potential unmet needs. Due to the cognitive decline experienced in a client diagnosed with neurocognitive disorder, communication skills may be limited. The client may become disoriented and frustrated. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Upon admission for symptoms of alcohol withdrawal, a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular bloodwork B. The client's mood and affect score, according to the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment

ANS: C There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which client statement demonstrates positive progress toward recovery from a substance use disorder? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my cravings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: D A client who takes responsibility for the consequences of substance use is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process, in which he or she accepts the fact that substance use causes problems. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance

A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

ANS: D Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Reduction of Risk Potential

A client diagnosed with major depressive disorder states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which reply by the nurse will best assess this client's affective symptoms? A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you ever felt this way before? C. "People who have mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"

ANS: D The nurse is using a clarifying statement in order to gather more details related to this client's mood. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

__________ disorder is characterized by mood swings from profound depression to extreme euphoria (mania), with intervening periods of normalcy

BIPOLAR DISORDER

Biochemical influences - Possible excess of ___________ and ______________

Biochemical influences - Possible excess of NOREPINEPHRINE and DOPAMINE

Client/Family Education: Lithium Notify physician if any of the following symptoms occur 1. 2. 3. 4.

Client/Family Education: Lithium - Notify physician if any of the following symptoms occur --- Persistent nausea and vomiting --- Severe diarrhea --- Ataxia --- Blurred vision

Client/Family Education: Lithium Notify physician if any of the following symptoms occur 5. 6. 7. 8.

Client/Family Education: Lithium - Notify physician if any of the following symptoms occur --- Tinnitus --- Excessive output of urine --- Increasing tremors --- Mental confusion

Client/Family Education: Lithium - Notify physician if ___________ or _______________ occur - Have serum lithium level checked every ______________, or as advised by physician

Client/Family Education: Lithium - Notify physician if vomiting or diarrhea occur - Have serum lithium level checked every 1 to 2 months, or as advised by physician

Client/Family Education: Lithium - Take the medication ______________ - Do not skimp on ___________________ - Drink ________________ water each day

Client/Family Education: Lithium - Take the medication regularly - Do not skimp on dietary sodium - Drink 6 to 8 glasses of water each day

__________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

MANIA

Nursing Diagnosis: _________________________ related to Egocentric and narcissistic behavior

Nursing Diagnosis: Impaired social interaction related to Egocentric and narcissistic behavior

Nursing Diagnosis: ____________________ related to Excessive hyperactivity and agitation

Nursing Diagnosis: Insomnia related to Excessive hyperactivity and agitation

Nursing Diagnosis: Risk for _________ related to Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements

Nursing Diagnosis: Risk for INJURY related to Extreme hyperactivity, increased agitation, and lack of control over purposeless and potentially injurious movements

What do these symptoms represent? Blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea

INITIAL SYMPTOMS OF LITHIUM TOXICITY

2. What is the speech pattern of a person experiencing a manic episode? More _ than usual or _ to keep _. ■ P_ _ _ _ _ _ _ _ speech: R_ _ _ _ speech that is l_ _ _, i_ _ _ _ _ _ _ _, and d_ _ _ _ _ _ _ _ to i_ _ _ _ _ _ _ _.

More TALKATIVE than usual or PRESSURE to keep TALKING. ■ Pressured speech: Rapid speech that is loud, intrusive, and difficult to interrupt.

Nursing Diagnosis: _____________________________ related to Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations

Nursing Diagnosis: Disturbed sensory perception related to Biochemical alterations in the brain and to possible sleep deprivation, evidenced by auditory and visual hallucinations

Nursing Diagnosis: ___________________________ related to Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment

Nursing Diagnosis: Disturbed thought processes related to Biochemical alterations in the brain, evidenced by delusions of grandeur and persecution and inaccurate interpretation of the environment

Nursing Diagnosis: ___________________________ related to Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea

Nursing Diagnosis: Imbalanced nutrition less than body requirements related to Refusal or inability to sit still long enough to eat, evidenced by loss of weight, amenorrhea

Onset of symptoms may reflect ____________ pattern

Onset of symptoms may reflect SEASONAL pattern

Select the Outcome Measure that would indicate the nurse writing it needs additional teaching: - Exhibits no evidence of physical injury - Has not harmed self or others - Is no longer exhibiting signs of physical agitation - Has achieved full recovery - Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status

Select the Outcome Measure that would indicate the nurse writing it needs additional teaching: - Exhibits no evidence of physical injury - Has not harmed self or others - Is no longer exhibiting signs of physical agitation -WRONG - Eats a well-balanced diet with snacks to prevent weight loss and maintain nutritional status

1. What is the most common medication that has been known to trigger manic episodes? Studies have shown that _ _, the most common medication used to prevent manic episodes, reduces expression of ANK3.

Studies have shown that LITHIUM CARBONATE, the most common medication used to prevent manic episodes, reduces expression of ANK3.

4. Why should a person on lithium therapy have blood levels drawn regularly? The m_ _ _ _ _ between the t_ _ _ _ _ _ _ _ _ _ and t_ _ _ _ levels of lithium carbonate is _ _. The usual ranges of therapeutic serum concentrations are as follows ■ For acute mania: ___ to ___ mEq/L ■ For maintenance: ___ to ___ mEq/L

The margin between the therapeutic and toxic levels of lithium carbonate is VERY NARROW. The usual ranges of therapeutic serum concentrations are as follows ■ For acute mania: 1.0 to 1.5 mEq/L ■ For maintenance: 0.6 to 1.2 mEq/L

Which of the following outcome criteria is appropriate (SATA) - Does not manipulate others for gratification of own needs - Interacts appropriately with others - Verbalizes that hallucinatory activity has ceased and shows outward behavior indicating presence of hallucinations -Is able to fall asleep within 30 minutes of retiring - Is able to sleep 6 to 8 hours per night

Which of the following outcome criteria is appropriate (SATA) - Does not manipulate others for gratification of own needs - Interacts appropriately with others - WRONG -Is able to fall asleep within 30 minutes of retiring - Is able to sleep 6 to 8 hours per night

9. The nurse is prioritizing nursing diagnoses in the plan of care for a client experiencing a manic episode. Number the diagnoses in order of the appropriate priority. ______ a. Disturbed sleep pattern evidenced by sleeping only 4 to 5 hours per night ______ b. Risk for injury related to manic hyperactivity ______ c. Impaired social interaction evidenced by manipulation of others ______ d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor

a = 3, b = 1, c = 4, d = 2 ______ b. Risk for injury related to manic hyperactivity ______ d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor ______ a. Disturbed sleep pattern evidenced by sleeping only 4 to 5 hours per night ______ c. Impaired social interaction evidenced by manipulation of others

4. Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? Select all that apply. a. Olanzepine (Zyprexa) b. Paroxetine (Paxil) c. Carbamazepine (Tegretol) d. Gabapentin (Neurontin) e. Tranylcypromine (Parnate)

a. Olanzepine (Zyprexa) c. Carbamazepine (Tegretol) d. Gabapentin (Neurontin)