Unit 5 EAQ
A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? a. Heroin b. Cocaine c. Nicotine d. Marijuana
c. Nicotine
A client reports to the primary healthcare provider with a complaint of becoming panicked and having irrational fear of public talking. Which drug does the nurse anticipate to be prescribed by the primary healthcare provider? 1 Buspirone 2 Alprazolam 3 Diazepam 4 Lorazepam
2 Alprazolam Alprazolam (a benzodiazepine) is a short-acting anxiolytic drug used to treat those clients with panic disorders and the irrational fear of talking openly in public (agoraphobia). Buspirone, an anxiolytic drug that is different both chemically and pharmacologically from the benzodiazepines, is always administered on a scheduled basis (not "as-needed") for the treatment of anxiety. Diazepam is an anxiolytic drug commonly prescribed for the treatment of anxiety but has generally been replaced by short-acting benzodiazepines. Lorazepam is an intermediate-acting anxiolytic drug used in the treatment of acutely agitated clients.
The parents of a newborn are told that their neonate may have Down syndrome and that additional diagnostic studies will be done to confirm this diagnosis. What procedure does the nurse expect to be performed? 1 Heel stick 2 Buccal smear 3 Urinary catheterization 4 Venous blood withdrawal
2 Buccal smear The cells in the buccal smear provide a pictorial analysis of chromosomes and show chromosomal abnormalities such as the trisomy found in Down syndrome. Blood from the heel stick is tested for inborn errors of metabolism such as phenylketonuria. Neither urine nor venous blood is not used to assess chromosomal aberrations.
What characteristics are commonly associated with adolescent depression? Select all that apply. 1 Exercising daily 2 Having suicidal ideation 3 Exhibiting tearfulness 4 Having poor muscle tone 5 Avoiding previously enjoyed activities and relationships
2 Having suicidal ideation 3 Exhibiting tearfulness 5 Avoiding previously enjoyed activities and relationships Having suicidal ideation, exhibiting tearfulness, and avoiding previously enjoyed activities and relationships are characteristic features of depression. Having poor muscle tone and performing physical exercise routine are uncommon in depressed adolescents.
A nurse is concerned when an 11-month-old infant is brought to the pediatric clinic weighing 9 lb 3 oz (4167 g). The nurse suspects that the infant is suffering from physical and emotional neglect. What observations lead the nurse to suspect maltreatment? Select all that apply. 1 Stranger anxiety 2 Inappropriate clothing 3 Social unresponsiveness 4 Frequent rocking motions 5 Adequate personal hygiene
2 Inappropriate clothing 3 Social unresponsiveness 4 Frequent rocking motions Stranger anxiety begins around 5 to 6 months, when infants become responsive to the caregivers who have met both physical and emotional needs. When strangers speak to them or reach out to hold them they seem fearful, cling to the caregiver, and cry. Infants whose needs have not been met adequately have no reason to be fearful of others. A typical sign of physical neglect is the wearing of dirty clothes or clothing that is not suitable to the environment. The infant who has not experienced social responsiveness from the caregiver has not learned how to be socially responsive to others. Infants who experience emotional deprivation resort to self-stimulating behaviors in an effort to meet their emotional needs. Infants who experience physical neglect are more likely to be unclean, with signs of unattended skin lesions such as diaper rash or bruises.
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? 1 "It must be frustrating to deal with your child's behavior." 2 "Have you considered any alternatives to using medication?" 3 "Perhaps you're looking for an easy solution to the problem." Incorrect4 "Let me teach you about the side effects of medications used for ADHD."
1 "It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.
A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Which questions does the nurse ask? Select all that apply. 1 "What brought you here for treatment today?" 2 "What do you believe is the cause of your depression?" 3 "Does religion have a role in your perception of health and wellness?" 4 "Do you have insurance that includes coverage of mental health issues?" 5 "Have you ever sought treatment for a mental health problem previously?"
1 "What brought you here for treatment today?" 2 "What do you believe is the cause of your depression?" 3 "Does religion have a role in your perception of health and wellness?" 5 "Have you ever sought treatment for a mental health problem previously?" Determining the client's perception of the problem is an appropriate question that allows cultural factors to be included. Encouraging the client to discuss the problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.
When working with a client who is depressed, what should the nurse do initially? 1 Accept what the client says. 2 Attempt to keep the client occupied. 3 Keep the client's surroundings cheery. 4 Try to prevent the client from talking too much.
1 Accept what the client says. Because clients cannot be argued out of their feelings, it is best to initially accept what they say; it also encourages communication. Attempting to keep the client occupied delays discussing the client's feelings, and the client's low energy level may prevent involvement in activities. Keeping the client's surroundings cheery has little effect on the depressed client; it can increase depression. The depressed client does very little talking and needs to be encouraged to communicate.
A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? 1 Anxiety and guilt 2 Anger and hostility 3 Embarrassment and shame 4 Hopelessness and powerlessness
1 Anxiety and guilt Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.
A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex? 1 Depression 2 Dependency 3 Marital stress 4 Identity confusion
1 Depression Decreased sexual desire is a major symptom of clinical depression. Other vegetative signs of depression include changes in bowel elimination, eating habits, and sleeping patterns. Although depression is often related to unmet dependency needs, the decreased sexual desire is associated with the depression, not the unmet dependency needs. The sexual difficulties are associated with the depression, and the depression, not the sexual difficulties, may be the major cause of marital stress. Also, there are no data indicating marital stress. Role confusion, not identity confusion, is usually associated with depression.
A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning, and the client no longer talks about suicide. What should the nurse do in response to this client's behavior? 1 Keep the client under close observation. 2 Arrange for the client to have more visitors. 3 Engage the client in preliminary discharge planning. 4 Observe the client for side effects of the medication.
1 Keep the client under close observation. As the client's motivation and energy return, the likelihood that suicidal ideation will be acted out increases. There are no data regarding visitation rights; the priority concern is the greater risk for suicide. Although engaging the client in preliminary discharge planning eventually will be done, the priority is determining the potential for suicide. Although the client should be observed for side effects of the medication, the greater risk of suicide takes precedence.
When the nurse is managing the care of an acutely depressed client, which intervention demonstrates that the nurse recognizes the client's fundamental mental health need? 1 Role modeling a hopeful attitude regarding life and the future 2 Sharing that life has presented depressing situations for all of us at times 3 Devoting time with the client and trying to focus on happy, positive memories 4 Identifying the client's personal weaknesses and designing interventions to strengthen them
1 Role modeling a hopeful attitude regarding life and the future Role modeling has been shown to be an excellent tool in molding adaptive behavior. Depression affects the individual's ability to see hope in the future, and role modeling will help provide adaptation to similar feelings. Affirming that everyone has depressive situations in their lives does not foster a positive response in the depressed client. Reminiscing about happier times and events is likely to highlight the client's current loss of happiness rather than foster positive feelings. The depressed client generally has low self-esteem and is often too tired to engage in physical activities. When a client is depressed, the nurse should identify the client's personal strengths, not weaknesses, and focus on interventions to reinforce those strengths. Focusing on a client's weaknesses when the client is already depressed may initiate a deeper depression.
A client is admitted to the psychiatric unit with the diagnosis of obsessive-compulsive disorder. The client washes her hands more than 20 times a day, and they are raw and bloody. What defense mechanism does the nurse conclude that the client is using to ease anxiety? 1 Undoing 2 Projection 3 Introjection 4 Displacement
1 Undoing Undoing is an act that partially negates a previous one; the client is using this defense mechanism to atone for unacceptable acts or wishes. The client is not attributing self-thoughts or impulses to another person or group, which is called projection. The client is not absorbing into the self a hated or loved object (introjection). Displacement is the transferring of feelings from one person, object, or experience onto another, less threatening person, object, or experience.
A 37-year-old man has been remanded by the court to the drug rehabilitation unit of a psychiatric facility for treatment of cocaine addiction. When taking his health history, what characteristics should the nurse expect the client to report? Select all that apply. 1 Anxiety 2 Palpitations 3 Weight loss 4 Sedentary habits 5 Difficulties with speech
1, 2, 3 Anxiety Palpitations Weight loss
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristics indicate to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply. 1 Thin upper lip 2 Wide-open eyes 3 Small upturned nose 4 Larger-than-average head 5 Smooth vertical ridge in the upper lip
1, 3, 5 Thin upper lip Samll upturned nose Smooth vertical ridge in the upper lip
The nurse assessing a newborn suspects Down syndrome. Which characteristics support this conclusion? Select all that apply. 1 Hypotonia 2 High-pitched cry 3 Rocker-bottom feet 4 Epicanthal eye folds 5 Single transverse palmar crease
1, 4, 5 Hypotonia Epicanthal eye folds Single transverse palmar crease Hypotonia is typical of newborns with Down syndrome. Their muscle tone is flaccid; they have less control of the head than a healthy newborn does because of their weak muscles. The single crease across the palm of the hand is typical of newborns with Down syndrome. Epicanthal eye folds give the newborn with Down syndrome the typical slant-eyed appearance. A high-pitched cry is characteristic of newborns with brain damage, cerebral irritability (opioid withdrawal), and cerebral edema (hydrocephaly). Rocker-bottom feet are found in newborns with trisomy 18.
Which sedative-hypnotics are used to treat insomnia effects associated with a panic disorder? Select all that apply. 1 Phenelzine 2 Paroxetine 3 Alprazolam 4 Imipramine 5 Clonazepam
3 Alprazolam 5 Clonazepam Alprazolam and clonazepam are examples of benzodiazepines, a class of sedative-hypnotics used to treat clients with insomnia effects associated with panic disorders. Phenelzine is a monoamine oxidase inhibitor used to treat panic disorders and promote sleep. Paroxetine is a selective serotonin reuptake inhibitor used to treat panic disorders and promote sleep. Imipramine is a tricyclic antidepressant used to treat panic disorders and promote sleep.
A client comes to the clinic for a 6-week postpartum check-up. She confides that she is experiencing exhaustion that is not relieved by sleep and feelings of failure as a mother because the infant "cries all of the time." When asked whether she has a support system, she replies that she lives alone. Which response would provide the most accurate information? 1 Providing information about a local support group 2 Explaining that it is normal to feel depressed after childbirth 3 Asking the client questions, using a postpartum depression scale 4 Suggesting that the client find someone who can take care of the baby for 24 hours
3 Asking the client questions, using a postpartum depression scale A postpartum depression scale is a validated tool for identifying women who might be experiencing postpartum depression. The most widely used and validated tools are the Edinburgh Postnatal Depression Scale and the Postpartum Depression Screening Scale. Although providing community resources of a local support group may be helpful, it is not useful in assessing the client's current emotional status. Although postpartum blues caused by hormonal changes soon after pregnancy might be common, feelings of depression and fatigue 6 weeks after childbirth is a matter of concern. The client may not have anyone else who can provide child care, or the client may not follow through on the recommendation. In addition, this intervention does not provide any information on the client's current emotional status.
A 37-year-old woman agrees to have a prenatal test done in order to diagnose fetal defects. There is a history of Down syndrome in her family. Which invasive prenatal test provides the earliest diagnosis and rapid test results? 1 Nonstress test 2 Amniocentesis 3 Chorionic villus sampling 4 Percutaneous umbilical blood sampling
3 Chorionic villus sampling Chorionic villus sampling may be performed between 10 and 12 weeks' gestation. The nonstress test, which is not invasive, is a technique used for antepartum evaluation of the fetus; it does not reveal fetal defects. Amniocentesis may be performed after 14 weeks' gestation, when sufficient amniotic fluid is available. Direct access to the fetal circulation with percutaneous umbilical blood sampling may be performed during the second and third trimesters.
Which drug is used to treat both generalized anxiety disorder and depression? 1 Fluoxetine 2 Bupropion 3 Duloxetine 4Mirtazapine
3 Duloxetine Duloxetine is an antidepressant drug used to treat both generalized anxiety disorder and depression. Fluoxetine is used to treat depression. Bupropion is used to treat depression and also aid in smoking cessation. Mirtazapine is used in the treatment of depression and also helpful in reducing the adverse sexual side effects in the male client receiving selective serotonin reuptake inhibitors therapy.
A nurse spends time in individual sessions helping a depressed, suicidal client verbalize feelings. For what themes should the nurse particularly listen? Select all that apply. 1 Anger 2 Control 3 Isolation 4 Dominance 5 Hopelessness 6 Indecisiveness
3 Isolation 5 Hopelessness Feelings of isolation compound feelings of hopelessness and helplessness and may provide the client with the impetus to act on suicide ideation. The main factor leading to acting on suicidal impulses is the feeling of hopelessness, that there is nothing to live for. Anger may be associated with depression; however, a depressed person usually does not have the energy to act out suicidal ideation. The struggle for control or dominance is not an important risk factor for suicide. Indecisiveness may be associated with depression, but an indecisive individual is usually unable to make the decision to commit suicide.
A client is prescribed the benzodiazepine alprazolam for the management of panic attacks. The nurse is confident that the medication information discussed has been understood when the client takes which action? 1 Removes the pepperoni from a pizza 2 Asks for an extra bottle of flavored water to drink with dinner 3 Requests a prescription for oral birth control before being discharged 4 States that chewable antacids may be taken to relieve heartburn
3 Requests a prescription for oral birth control before being discharged Benzodiazepines increase the risk of congenital anomalies and so should not be taken by pregnant women. Refraining from eating pepperoni is appropriate for people taking monoamine oxidase inhibitors because tyramine needs to be strictly avoided. Appropriate hydration is critical for those taking lithium. Antacids can affect both absorption and metabolism of benzodiazepines and should be avoided.
A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1 Undoing 2 Projection 3 Suppression 4 Intellectualization
3 Suppression Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.
An older client who lost a spouse 20 years ago comes to the community health center with a vague list of complaints and a brief life history. The couple's only child died at birth. The client lives alone and is able to perform all the activities of daily living. The client has had an active social life in the past but has outlived many friends and family members. What is an important question for the nurse to ask when taking this client's health history? 1 "Are you all alone?" 2 "How did your son die?" 3 "Do you still miss your spouse?" 4 "How do you feel about your life now?"
4 "How do you feel about your life now?" The answer to "How do you feel about your life now?" will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Are you all alone?" is probing and provides little information for the nurse to use in planning care. "How did your son die?" and "Do you still miss your spouse?" are both probing, disregard the client's present situation, and provide little information for the nurse to use in planning care.
A 7-year-old boy with a diagnosis of attention deficit-hyperactivity disorder (ADHD) is receiving methylphenidate. His mother asks about its action and side effects. What is the nurse's initial response? 1 "This medicine increases the appetite." 2 "This medicine must be continued until adulthood." 3 "It is a short-acting medicine that must be given with each meal." 4 "It is a stimulant that has a calming effect on children with your son's disorder."
4 "It is a stimulant that has a calming effect on children with your son's disorder."
On the third postpartum day, the nurse enters the room of a client who had an unexpected cesarean birth and finds her crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" What should the nurse consider when responding? 1 The client's feelings will pass after she has bonded with her infant. 2 The client is probably suffering from postpartum depression and needs special care. 3 A cesarean birth may be a traumatic experience, but most women know that it is a possible outcome. 4 A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this.
4 A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this. The client's response is appropriate to the situation, reflecting disappointment in not achieving her goal; in addition, this is the time when "postpartum blues" occurs. The client's feelings may or may not pass after she has bonded with her infant; there is no indication that the feeling will pass or that bonding is involved. The client's statement is not indicative of depression. With rising cesarean rates across the United States, most women know that a cesarean birth is a real possibility. However, knowing this does not negate the disappointment a client may feel over not reaching her goal.
The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to? 1 Modifying the environment 2 Limiting the client's choices of diet and clothing 3 Encouraging fluid intake 4 Discouraging social interaction to avoid the client's distraction from outside environment
4 Discouraging social interaction to avoid the client's distraction from outside environment The nursing student's act of discouraging interactions due to fear of the client's distraction may result in a lack of improvement. Social interactions should be encouraged instead. Modifying the environment may help to provide better healthcare. The nurse should limit the client's choices of food and clothing to relieve any decision-making stress. The nurse should also encourage fluid intake.
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? 1 Are unaware that the ritual serves no purpose 2 Can alter the ritual depending on the situation 3 Should be prevented from performing the ritual 4 Do not want to repeat the ritual but feel compelled to do so
4 Do not want to repeat the ritual but feel compelled to do so The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.
A nurse is caring for a child with autism. Which intervention is most appropriate in an attempt to promote socialization for this child? 1 Encouraging participation in group activities 2 Providing minimal environmental stimulation 3 Holding and cuddling the child for short periods 4 Imitating and participating in the child's activities
4 Imitating and participating in the child's activities The nurse should begin by attempting to enter the world where the child's attention is currently focused; this is a way of establishing human contact, because the child's usual contacts are inanimate objects. Children with autism have deficits in social development, and relationships are difficult to establish. Autistic children are generally unable to participate in group activities. Providing minimal environmental stimulation will have no effect on the nurse's ability to reach the child; rather, it will reinforce withdrawal. Autistic children generally cannot tolerate body contact and will become rigid when anyone attempts to initiate it.
A client who suspects that she is 6 weeks pregnant appears mildly anxious as she is waiting for her first obstetric appointment. What symptom of mild anxiety does the nurse expect this client to experience? 1 Dizziness 2 Breathlessness 3 Abdominal cramps 4 Increased alertness
4 Increased alertness Increased alertness is an expected common behavior that occurs in new or different situations when a person is mildly anxious. Dizziness, breathlessness, and abdominal cramps are all common signs of moderate to severe anxiety.
An older adult who is undergoing follow-up treatment for mild depression at a local walk-in mental health clinic reports the onset of nausea, headache, and episodes of double vision during the past few weeks. In light of the assessment information, what is the nurse's priority? 1 Performing an in-depth cardiac assessment 2 Arranging for an ophthalmic consultation immediately 3 Initiating a conversation about the son's cancer diagnosis 4 Inquiring when the client began therapy for hypertension
4 Inquiring when the client began therapy for hypertension Calcium channel blockers such as diltiazem can cause neurotoxin symptoms like the ones the individual is describing when taken in combination with a selective serotonin reuptake inhibitor (SSRI) such as citalopram. Although the client is taking a calcium channel blocker for hypertension, there is no indication that there is a cardiac cause of the symptoms. Diplopia (double vision) is an abnormal condition and will require further attention but is not the priority at this point in time. The son's cancer diagnosis is a potential source of anxiety and depression, but the physical symptoms are not classically seen in either of those emotional states.
A team approach is used to help a 6-year-old boy with attention deficit-hyperactivity disorder (ADHD). What behaviors indicate that the interventions have been effective? Select all that apply. 1 Is not inhibited by rules or routines 2 Has fun playing with toys by himself 3 Is no longer enuretic during the night 4 Has an increased attention span in school 5 Is able to wait his turn when in line with others
4, 5 Has an increased attention span in school Is able to wait his turn when in line with others One characteristic of children with ADHD is the inability to remain focused on any activity; an increased attention span in school indicates that the child has improved. Other characteristics of children with ADHD are impulsivity, impatience, and the inability to delay gratification; the ability to wait for one's turn in line indicates that the child has improved. A lack of inhibition by rules or routines indicates that the child has not made sufficient progress and his behavior is still impulsive. Having fun playing with toys by himself indicates that the child has not made progress because children should enjoy playing with peers at this age. A 6-year-old child usually does not experience nocturnal enuresis; there are no data to indicate that the child had enuresis.
A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? (Select all that apply.) a. A motivational interview b. Observing for stress reaction c. Converting narcotic use from an illicit to a legally controlled drug d. Observing for delirium tremens e. Encouraging involvement in Narcotics Anonymous
a, b, e The motivational interview will help determine the patient's readiness to participate in therapies. Stress reaction is a withdrawal symptom that can occur when detoxification takes place too quickly. Support groups have been shown to be successful for drug addiction. Delirium tremens is usually associated with alcohol withdrawal.
A registered nurse provides dietary instructions to a client who is prescribed isocarboxazid for depression. Which statements made by the client indicates a need for further education? Select all that apply. a. "I will limit my intake of coffee." b. "I will limit my intake of yogurt." c. "I will include bananas in my diet." d. "I will limit my intake of red wine." e. "I will add dark chocolates to my diet."
a. "I will limit my intake of coffee." b. "I will limit my intake of yogurt." d. "I will limit my intake of red wine."
After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? a. Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min b. Blood pressure of 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths/min c. Blood pressure of 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths/min d. Blood pressure of 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths/min
a. Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min (opioids depress the respiratory system)
A client is admitted to the psychiatric unit for severe depression with the potential for suicide. What is the most therapeutic nursing intervention when the client becomes more energized and communicative? a. Continuing to assess the client at regular intervals b. Encouraging the client to participate in group activities c. Giving the client more autonomy to decide about privileges d. Starting to teach the client about medications in preparation for discharge
a. Continuing to assess the client at regular intervals
During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. a. Lethargy b. Ambivalence c. Emotional lability d. Increased appetite e. Long periods of sleep
a. Lethargy b. Ambivalence c. Emotional lability
The nurse suspects that a patient who was prescribed fentanyl for pain management is abusing the medication and is now in withdrawal. What finding does the nurse expect? a. Nausea and diarrhea b. Tremors and seizures c. Lethargy and disorientation d. Delusions and hallucinations
a. Nausea and diarrhea
A new mother is diagnosed with depression. Which antidepressant may be prescribed to this client? a. Sertraline b. Fluoxetine c. Amphetamine d. Carbamazepine
a. Sertraline Sertraline is considered safe in lactating females. Dosing immediately after breast-feeding can reduce the risk of the drug excreted in the breast milk by the next feeding time. Fluoxetine and amphetamine are not recommended for breast-feeding clients. Carbamazepine is not used to treat depression.
A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? Select all that apply. a. Tremors b. Anorexia c. Agitation d. Delusions e. Confusion
a. Tremors b. Anorexia
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. a. Describes how others have caused the addiction b. Verbalizes difficulty identifying personal strengths c. Expresses uncertainty about meeting with the nurse d. Acknowledges the effects of the addiction on the family e. Addresses how the addiction has contributed to family distress
b. Verbalizes difficulty identifying personal strengths d. Acknowledges the effects of the addiction on the family e. Addresses how the addiction has contributed to family distress
A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when the client states that what is one major disadvantage of ECT? a. The seizures may cause bone fractures b. Relief of symptoms requires many weeks of treatment c. Memory is impaired just before and after the treatment d. Loss of mental function occurs and continues for a long time
c. Memory is impaired just before and after the treatment Impaired memory is an expected side effect of the therapy. Succinylcholine prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.
The nurse suspects alcohol abuse in a patient who was recently admitted to the emergency department following a motor vehicle accident. Which assessment finding would alert the nurse to ask the patient about alcohol use? a. Low blood pressure Incorrect b. Decreased heart rate c. Elevated temperature d. Abdominal tenderness
d. Abdominal tenderness Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in patients with chronic alcohol use. Elevated blood pressure and heart rate is associated with alcohol abuse. Temperature variations are not associated with alcohol abuse.
The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement? a. Teaching the client about normal newborn care b. Ensuring adequate bonding time with the infant c. Giving the client time and space to express her feelings d. Referring the client to a psychiatric healthcare provider as prescribed
d. Referring the client to a psychiatric healthcare provider as prescribed
An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? a. Providing psychotherapy to the client b. Teaching strategies to overcome depression c. Encouraging the client to walk for 30 minutes d. Requesting that the physician change the drug
d. Requesting that the physician change the drug Tricyclic antidepressants have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence in older adults.
The nurse is assessing a patient's anxiety related to stress. Which changes reflect the short-term physiologic response to stress? (Select all that apply.) a. Cortisol is released, increasing glycogenesis and reducing fluid loss. b. Immune system functioning decreases, and the risk of cancer increases. c. Corticosteroid release increases stamina and impedes digestion. d. Muscular tension, blood pressure, and triglyceride levels increase. e. Epinephrine is released, increasing the heart and respiratory rates. f. Risk of depression, autoimmune disorders, and heart disease increases.
a, c, d, e The correct answers are all short-term physiologic responses to stress. Increased risk of immune system dysfunction, cancer, cardiovascular disease, depression, and autoimmune disease are all long-term (chronic) effects of stress.
The nurse is providing care to an infant diagnosed with Down syndrome. Which parental statement related to the infant's growth indicates the need for further education? 1 "My baby will have growth deficiencies during infancy." 2 "My child will have accelerated growth during adolescence." 3 "My child will most likely be overweight by 3 years of age." 4 "My baby will have reduced growth in both height and weight."
2 "My child will have accelerated growth during adolescence." Children diagnosed with Down syndrome will often have growth deficiencies. These deficiencies are most pronounced during adolescence and infancy. Because weight gain is more rapid than growth in stature, many children with Down syndrome are overweight by 3 years of age. Overall reduced growth is noted for both height and weight.
Which symptoms of depression, often overlooked in the older adult client, should the nurse include in the assessment process? Select all that apply. 1 Anxiety 2 Insomnia 3 Weight loss 4 Weight gain 5 General fatigue
2 Insomnia 5 General fatigue Insomnia and general fatigue are symptoms of depression that are often overlooked for the older adult client. Anxiety, weight loss and weight gain are all symptoms of depression; however, these symptoms are not often overlooked for the older adult client.
A 3-year-old client has been admitted to the pediatric unit for dehydration resulting from nausea and vomiting. The parents tell the nurse the child has autism and resists being held, acts as if deaf, frequently mimics words or phrases, and is not toilet trained. What is most important for the nurse to do when planning care for this child? 1 Provide a structured routine for the child to follow while in the hospital 2 Involve the parents in the plan of care and encourage their being with the child as much as possible 3 Place the child in a semiprivate room near the nurses' station where activities can be seen and heard 4 Assign different personnel to the child until it is determined which staff members the child relates to best, and then use them to enhance the nurse-child relationship
2 Involve the parents in the plan of care and encourage their being with the child as much as possible The parents should stay with the child during hospitalization to preserve stability and consistency for the child. Although providing a structured routine is important, it is not the priority. Ensuring parental support is the priority. Decreased stimulation is essential; using a private room and avoiding extraneous auditory and visual distraction may decrease the disruptiveness of hospitalization. Assigning different personnel will increase the irritability and frustration of the child; consistency and stability are essential for the child's well-being, and the same staff members should be assigned to care for the child.
A nurse is teaching the parents of a child with attention deficit hyperactivity disorder (ADHD) about the prescribed medication methylphenidate. When will the daily dose be administered? 1 Before breakfast 2 Just after breakfast 3 Immediately before lunch 4 As soon as the child awakens
2 Just after breakfast Methylphenidate is an appetite suppressant; it should be given after meals. Methylphenidate given before a meal or as soon as the child awakens may suppress the child's appetite.
After a child's visit to a healthcare provider, the parent tells the nurse, "I'm so upset! The doctor prescribed an antidepressant!" What is the best response by the nurse? 1 "Tell me more about what's bothering you." 2 "Weren't you told why your child needs an antidepressant?" 3 "You need to speak with the healthcare provider about your concerns." 4 "Are you sure it's an antidepressant and not a drug for attention deficit disorder?"
1 "Tell me more about what's bothering you." "Tell me more about what's bothering you" provides an opportunity to explore the parent's feelings. It is the nurse's responsibility, not the healthcare provider's, to assess the parent's concerns before planning further interventions. "Weren't you told why your child needs an antidepressant?" is a confrontational response that may put the parent on the defensive. "Are you sure it's an antidepressant and not a drug for attention deficit disorder?" is a judgmental, nontherapeutic response that may worsen the parent's concerns.
The nurse is providing instructions to a client who is on isocarboxazid for depression. Which statements made by the client indicate effective learning? Select all that apply. 1 "I will include yogurt in my diet." 2 "I will avoid soy sauce in my diet." 3 "I will avoid pepperoni in my diet." 4 "I will include cream cheese in my diet." 5 "I will avoid fermented bean curds in my diet."
1 "I will include yogurt in my diet." 4 "I will include cream cheese in my diet." 5 "I will avoid fermented bean curds in my diet." Isocarboxazid is a monoamine oxidase (MAO) inhibitor used to treat depression. Clients on MAOIs should avoid foods containing high amounts of tyramine. Yogurt and cream cheese are foods containing low to no tyramine content. Fermented bean curds are high tyramine-containing foods that should be avoided. Soy sauce and pepperoni are high tyramine foods that should be avoided.
Which medications are used to treat generalized anxiety disorder (GAD)? Select all that apply.: 1 Duloxetine 2 Venlafaxine 3 Clonazepam 4 Escitalopram 5 Clomipramine
1 Duloxetine 2 Venlafaxine 4 Escitalopram Duloxetine, venlafaxine, and escitalopram are antidepressants approved for the treatment of generalized anxiety disorder (GAD). Clonazepam and clomipramine are used to treat panic disorders.
The nurse is caring for a child who has attention deficit-hyperactivity disorder (ADHD). Which changes in the child's classroom will be beneficial? Select all that apply. 1 Providing breaks frequently at regular intervals 2 Writing instructions on the blackboard after verbalization 3 Increasing the number of classroom assignments and homework 4 Improving the writing skills of the child compared with computer skills 5 Scheduling academic subjects for times when the child is under the effect of medication
1, 2, 5 Providing breaks frequently at regular intervals Writing instructions on the blackboard after verbalization Scheduling academic subjects for times when the child is under the effect of medication
A 12-year-old child with Down syndrome is admitted to the hospital for intravenous antibiotics for pneumonia. Which clinical findings associated with Down syndrome should the nurse expect when performing a physical assessment? Select all that apply. 1 Saddle nose 2 Thin fingers 3 Inner epicanthic folds 4 Hypertonic musculature 5 Transverse palmar crease
1, 3, 5 Saddle nose Inner epicanthic folds Transverse palmar crease Children with Down syndrome have a broad nose with a depressed bridge (saddle nose), as well as inner epicanthic folds and oblique palpebral fissures; they also have speckling of the iris (Brushfield spots). Children with Down syndrome have a transverse palmar crease (simian crease) formed by fusion of the proximal and distal palmar creases. These children also have broad, short, stubby hands and feet. Children with Down syndrome have hypotonic, not hypertonic, musculature.
What strategy should the nurse employ to be effective when using play therapy with a 6-year-old child with autism? 1 Play music and dance with the child. 2 Use mechanical and inanimate objects for play. 3 Employing positive reinforcements such as hugging. 4 Provide brightly colored toys and blocks that can be held.
2 Use mechanical and inanimate objects for play Self-isolation and disinterest in interpersonal relationships lead the autistic child to find security in nonthreatening, impersonal objects. Dancing with the child is too threatening for a child with autism because of the close personal contact it requires. Close interaction, such as hugging, with others is too threatening for a child with autism. These children do not respond to brightly colored toys and blocks as other children do unless movement is involved.
A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. 1 Seizures 2 Yawning 3 Drowsiness 4 Constipation 5 Muscle aches
2, 5 yawning muscle aches
Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply.) a. Assess for bradycardia b. Ask about epigastric pain c. Observe for increased appetite d. Check for elevated blood glucose levels e. Monitor for a decrease in respiratory rate
b, c, d The physiologic changes associated with the acute stress response can cause changes in appetite, increased gastric acid secretion, and elevation of blood glucose levels. Stress causes an increase in respiratory and heart rates.
A young adult being treated for substance abuse asks the nurse about methadone. The nurse responds that methadone is useful in the treatment of opioid addiction because it has what characteristic? a. Is a nonaddictive drug b. Has an effect of longer duration c. Does not produce a cumulative effect d. Carries little risk of psychological dependence
b. Has an effect of longer duration The duration of effect of methadone is 12 to 24 hours, compared with other opioids, which have a 3- to 6-hour duration of effect. It is just as addictive but controls the addiction and keeps the client out of the illicit drug market.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. 1 Describes how others have caused the addiction 2 Verbalizes difficulty identifying personal strengths 3 Expresses uncertainty about meeting with the nurse 4 Acknowledges the effects of the addiction on the family 5 Addresses how the addiction has contributed to family distress
2, 4, 5 Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress
A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions? 1 Hold the child. 2 Place the child in time-out. 3 Use another activity to distract the child. 4 Determine the reason for the child's behavior
3 Use another activity to distract the child. Providing a constructive distraction will help redirect the autistic child's behavior. Physical contact provokes anxiety for the autistic child. A time-out is punitive and is not constructive. The reason for this repetitive behavior is unknown.
A nurse is using cognitive therapy to help a client who experiences panic attacks. What is the goal of this therapy? 1 Preventing future panic attacks 2 Helping the client hide the panic attacks 3 Stopping the panic attacks once they begin 4 Decreasing the fear of having panic attacks
4 Decreasing the fear of having panic attacks It is the fear of having an attack as much as the panic attack itself that is debilitating. Once the client's fear of future attacks is diminished, the number of attacks usually decreases as well. Prevention of future attacks is desirable but not always possible.
A 15-year-old adolescent with Down syndrome is scheduled for surgery. The parents inform the nurse that their child has a mental age of 8 years. At what age level should the nurse prepare the child's preoperative teaching plan? 1 Adult, for the parents to understand 2 Specific age, as ordered by the healthcare provider 3 Adolescent, because this is the child's chronologic age 4 School-age, because this is the child's developmental age
4 School-age, because this is the child's developmental age
For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply. a. Irritability b. Tachycardia c. Hallucinations d. Increasing anxiety e. Profuse diaphoresis
a. Irritability d. Increasing anxiety
