Term
| The nurse in the emergency room is caring for a client who was found wandering, confused and frightened, in a local park. The client tells the nurse his name and address, but says he has no idea what has happened to him and how he got here. Which condition does the nurse recognize? |
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Definition
Dissociative fugue
Dissociative fugue is rare and occurs most often under conditions of war, natural disasters, or intense psychosocial stress. Clients with dissociative fugue often are picked up by the police when they are found wandering in a somewhat confused and frightened condition after emerging from the fugue in unfamiliar surroundings. They are usually presented to emergency departments of general hospitals. On assessment, they are able to provide details of their earlier life situation but have no recall from the beginning of the fugue state. |
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Term
| Which of the following nursing interventions has long-term implications for a depressed and suicidal client? |
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Definition
Assist the client to develop more effective coping mechanisms.
Long-term therapy should be directed toward assisting the client to cope effectively with stress. |
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Term
| Which client would be at the highest risk for experiencing somatoform pain disorder? |
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Definition
45-year-old female blue-collar factory worker.
Somatoform pain disorder is most frequently seen in female clients between the ages of 40 and 50. It is also more common in so-called blue-collar occupations, perhaps because of the increased likelihood of job-related injuries. |
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Term
| The nurse is caring for a client who states that she is terrified that she has a brain tumor. She has been worked up repeatedly for headaches, and all test results are negative for tumors, as well as other disorders. The client is still convinced that she must have a tumor. What disorder does the nurse suspect? |
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Definition
Hypochondriasis
Hypochondriasis is defined as an unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease. This client is unnaturally fearful of having cancer, despite the fact that all of her tests have shown to be normal. |
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Term
| The nurse is developing a care plan for a client with a paranoid personality disorder. The client is hospitalized after yelling and calling the police repeatedly regarding the neighbors who are plotting against the client. The nurse wishes to assist the client to be less socially isolated. Which of the following goals would be most reasonable during this hospitalization? |
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Definition
Exercise reasonable control over own environment
Feelings of helplessness and lack of control can reinforce this client's suspicions and pattern of social isolation. The client and nurse must work jointly toward the goal of ensuring that the client has as much control as possible. |
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Term
A client was experiencing extrapyramidal symptoms secondary to neuroleptic drug therapy. The physician ordered biperiden (Akineton) 2 mg tid IV. Using a 5 mg/mL vial, how many milliliters did the nurse administer? (Fill in the blank.)
Answer: |
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Definition
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Term
| In assessing a client with borderline personality disorder, the nurse would expect which of the following traits? |
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Definition
Little tolerance for being alone
Clients diagnosed as having a borderline personality disorder have little tolerance of being alone. |
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Term
| A physician prescribes a 90-day supply of antidepressants for a client who has suicidal ideation. What is the appropriate nursing intervention? |
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Definition
Question the physician about the length of the order (90-day supply).
As depression lifts, patients become energized and are thus able to put their suicidal plans into action. The nurse should question the physician's order for a 90-day supply of medications, since it is wise to prescribe no more than a 3-day supply of the medication with no refills. The prescription can then be renewed at the client's next counseling session. |
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Term
| The nurse is planning care for a client who has attempted suicide. Which reflects the appropriate outcome criteria? |
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Definition
The client will express optimism about the future.
Expressing optimism about the future indicates that the client has something to live for. |
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Term
| The nurse evaluates the outcome of the expected treatment for eating disorders by asking which question? |
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Definition
Does client accept self as less than perfect?
The nurse evaluates the outcome by asking the client if she accepts herself as being less than perfect. |
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Term
| A client is admitted with a diagnosis of anorexia nervosa. During the initial interview, the nurse determines that the client lacks a sense of competence except for weight control. Which term does the nurse assign to this phenomenon? |
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Definition
Paralyzing sense of ineffectiveness
A lack of a sense of competence in any area outside of weight control is known as a paralyzing sense of ineffectiveness. The other terms do not apply to this concept. |
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Term
| A client diagnosed as having borderline personality disorder presents to the mental health clinic and demands to see a counselor immediately. Which is the appropriate nursing action? |
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Definition
Explain the rules and set limits.
Clear boundaries and set limits will provide firm structure necessary for clients diagnosed with a personality disorder. |
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Term
| Which of the following clients whom the nurse is caring for are at a particularly high risk for suicide? (Select all that apply.) |
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Definition
A newly retired man with severe insomnia.
A male teenager who is struggling to acknowledge his homosexuality.
A chronic schizophrenic who hears command hallucinations to harm himself.
The man who is newly retired has multiple risk factors (gender, age, change in employment, and severe insomnia) that could indicate the potential for suicide. Women are at lower risk for suicide than men, and married people are at lower risk than those who are single. Adjustment disorder is not a high-risk diagnosis for suicide. Gay and lesbian youths are two to three times more likely to commit suicide. Schizophrenics who have command hallucinations to harm themselves are at high risk for suicide. The business executive has the fewest risk factors (no diagnosed psychiatric disorder). |
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Term
| A client is about to undergo electroconvulsive therapy (ECT). Which statement most accurately reflects the nurse's role during ECT? |
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Definition
Assist the individual performing ECT
One of the nurse's roles is to assist the individual performing ECT. |
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Term
| The nurse should include which teaching about the tricyclic group of antidepressant medications? |
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Definition
Their full therapeutic potential may not be reached until 4 weeks.
It may take several weeks for tricyclic medications to reach their full therapeutic effect. |
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Term
| A client with hypochondriasis is fearful of many disease processes. In planning care, which are appropriate nursing interventions? |
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Definition
Assess what function the client's illness is fulfilling for him or her.
Encourage the client to discuss feelings associated with fear of serious illness.
Understanding what function the illness serves for the client is important in identifying maladaptive behaviors. It is important to encourage the client to discuss feelings associated with fear of serious illness. Verbalization of feelings in a nonthreatening environment facilitates expression and resolution of disturbing emotional issues. When the client can express feelings directly, there is less need to express them through physical symptoms. Assuring the client that he or she does not have a disease is nontherapeutic, as this belittles the client's feelings. It is also important to rule out any organic causes for the client's concerns. Refer all new physical complaints to the physician. To assume that all physical complaints are hypochondriacal would place the client's safety in jeopardy. The nurse should convey empathy to the client, but not sympathy. Empathy lets the client know that you understand how a specific symptom may conjure up fears of previous life-threatening illness. Unconditional acceptance and empathy promote a therapeutic nurseclient relationship. |
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Term
| A client attends the psychiatric day-treatment program. He was referred by his probation officer for treatment after being arrested for driving under the influence of substances. He has a history of many arrests for assault, grand larceny, and other serious crimes and has served two prison sentences. His diagnosis is antisocial personality disorder. Which of the following comment on past behavior would the nurse expect from the client? |
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Definition
It's not my fault.
People with antisocial personalities lack remorse about their actions and view themselves as victims. In this scenario, the client would refuse to acknowledge his responsibility in the precipitating events. |
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Term
A client is diagnosed with exogenous obesity. The physician orders amphetamine sulfate 20 mg PO AC. On hand were 10-mg tablets. The nurse instructed the client to take how many tablets? (Fill in the blank.)
Answer: |
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Definition
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Term
| A client diagnosed with a bipolar disorder continues to be hyperactive and to lose weight. The nurse expects which of the following nutritional interventions would be most therapeutic for the client at this time? |
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Definition
Provide small, frequent feedings of foods that can be carried.
The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow the client to eat during periods of activity. |
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Term
An alcoholic was given scopolamine hydrobromide 0.4 mg SC to calm the delirium he was experiencing. Using a 1 mg/mL vial, how many milliliters did the nurse administer SC? (Fill in the blank.)
Answer: |
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Definition
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Term
| One nurse witnesses another nurse preparing to give an injection to a client immediately prior to electroconvulsive therapy (ECT). Which medication that is being drawn up should the nurse question? |
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Definition
Glycopyrrolate (Robinul)
Thiopental sodium (Pentothal), methohexital sodium (Brevital) and succinylcholine chloride (Anectine) can all be given immediately before ECT. Glycopyrrolate (Robinul) should have been given 30 minutes before treatment. |
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Term
| In the initial stages of caring for a client experiencing an acute manic episode, what should the nurse consider to be the priority nursing diagnosis? |
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Definition
Risk for injury related to excessive hyperactivity
Maintaining client safety is always a priority according to Maslow's hierarchy of needs. The impulsiveness and hyperactivity seen in clients with acute mania puts them at risk for injury. |
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Term
| The physician informs the client that succinylcholine chloride (Anectine) would be administered before ECT. When the client asks why must I take this medication? which is the appropriate nursing response? |
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Definition
To relax skeletal muscles during the ECT procedure.
Succinylcholine chloride is the medication of choice used to relax the skeletal muscles prior to ECT to prevent bone fractures during the induced convulsion. |
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Term
| What should the nurse plan to teach a client who is taking alprazolam (Xanax) three times a day? |
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Definition
The potential for dependence and tolerance
Benzodiazepines are addictive. It is the responsibility of the nurse to teach the client about dependence, tolerance, and more effective coping skills. |
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Term
| A nurse has completed discharge instructions. Which documentation statement best reflects the information has been learned? |
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Definition
The client demonstrated self-injection of ordered insulin.
Watching a client perform a return demonstration effectively demonstrates that learning has taken place. Giving the client content or pamphlets does not guarantee that learning has taken place. |
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Term
| In evaluating a client who has had electroconvulsive therapy (ECT) several days prior, which outcome would indicate that the treatment had been effective? |
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Definition
The client's affect is brighter than before treatment.
An elevation in mood indicates that treatment has been effective. |
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Term
| The physician prescribes methylphenidate (Ritalin) for the client. The nurse understands that the mechanism of action for methylphenidate is which of the following? |
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Definition
Increases levels of neurotransmitters thus increasing motor activity.
Methylphenidate (Ritalin) increases the level of neurotransmitters producing central nervous system and respiratory stimulation, dilated pupils, and increased motor activity. |
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Term
| A client will undergo electroconvulsive therapy (ECT) tomorrow. Which client statement to the nurse would indicate that the client is not ready to undergo ECT? |
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Definition
I have a brain tumor.
This statement indicates that the client either does not understand the indications for ECT, or, if indeed he or she has a brain tumor, then ECT is contraindicated. (The only absolute contraindication for ECT is increased intracranial pressure [from brain tumor, recent cardiovascular accident, or other cerebrovascular lesion].) |
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Term
| A client calls the eating disorders clinic for an appointment. She was hospitalized and diagnosed with anorexia nervosa when she was 14 years old. She is nervous about starting a job and wants to perform perfectly. She tells the nurse that she has been taking laxatives every day, and that some days after eating she self-induces vomiting. She is 5'6'' tall and weighs 105 pounds. Her plan of care will be based on which primary nursing diagnosis? |
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Definition
Imbalanced Nutrition, less than body requirements
She is very underweight due to self-induced vomiting and laxative abuse. Her nutritional status is compromised and this takes priority over the other psychological nursing diagnoses. |
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Term
| A client has been diagnosed with major depression. The psychiatrist prescribes imipramine (Tofranil). What client teaching specific to this class of antidepressants should the nurse include? |
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Definition
The medication may cause photosensitivity.
Dry mouth, nausea, and discontinuation syndrome can occur with all antidepressants. Photosensitivity most commonly occurs with tricyclics, such as imipramine. |
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Term
| The physician orders fluoxetine (Prozac) for a depressed client. Which of the following pharmacodynamic should the nurse expect with fluoxetine? |
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Definition
The therapeutic effect of the drug occurs 2 to 4 weeks after treatment is begun.
This statement is true. The nurse should anticipate that the full therapeutic effect might not manifest for 2 to 4 weeks after beginning treatment. |
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Term
| A client with antisocial personality disorder is admitted for psychological testing. The client reports running away from home and parents on two occasions after setting the house on fire. Which reflects the priority nursing intervention? |
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Definition
Discuss alternatives to pyromania.
Exploring with the client alternative ways of handling frustration is a nursing priority. |
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Term
| A client suffering from numbness of the extremities, trembling, and dyspnea is admitted with a diagnosis of severe anxiety disorder. Which reflects an appropriate initial nursing intervention? |
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Definition
Provide safety and comfort.
Clients exhibiting severe anxiety require immediate reassurance of safety and security according to Maslow's hierarchy of needs. |
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Term
| The nurse is caring for four clients. Based on knowledge and statistics associated with suicidal risk, which client does the nurse recognize as more predisposed to a suicide attempt? |
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Definition
Male of very high socioeconomic status
Males are more likely to complete a suicide attempt than females; those of very high and very low socioeconomic statuses are more likely to attempt suicide than are persons of the middle class. |
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Term
| A client is admitted to the psychiatric unit. During the assessment interview, the nurse determines that the client is shy, sensitive, stubborn, and extremely underweight. Which of the following statements made by the client primarily would help the nurse determine that there is an eating disorder present? |
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Definition
I have not had a menstrual period in 6 months and I'm not pregnant.
A diagnostic criterion for anorexia nervosa is amenorrhea of at least three consecutive menstrual cycles. |
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Term
| Which of the following nursing interventions are consistent with the outcome criteria for a suicidal client? (Select all that apply.) |
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Definition
Accept the client with unconditional positive regard.
Encourage the client to talk about his or her pain.
Provide the client with tasks to occupy his or her time.
Accepting the client with unconditional positive regard, encouraging discussion about his or her pain, and providing tasks to occupy time are part of a plan of care for the suicidal client that builds rapport and distracts the client from suicidal thoughts. A suicidal client must be under increased supervision so that interventions can quickly occur if there are any actions that could be self-injurious. |
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Term
| During assessment, the nurse anticipates which behavior would be expected of bulimic clients? |
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Definition
Are within their normal weight range.
Individuals with bulimia are often able to maintain a normal weight while binge eating through purging. |
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Term
| A client is being treated with sertraline (Zoloft) for a major depressive episode. One week after medication initiation, the client tells the nurse, I've only been taking this drug for a week but I'm sleeping better and my appetite has improved. The nurse concludes that: |
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Definition
The rapid onset of Zoloft can improve insomnias and appetite disturbances as early as 1 week after initiation.
Zoloft is known to improve middle and terminal insomnia, appetite disturbances, and anxiety as early as 1 week after drug initiation. |
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Term
| In caring for a client diagnosed with borderline personality disorder, the care plan provided by the nurse should include which of the following? |
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Definition
Observe client's behavior frequently
Close observation is required so that intervention can occur if required to ensure safety of the client and others. |
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Term
| At the time of admission, a client is suffering from insomnia, shortness of breath, and a rapid pulse. The client is agitated, and reports feelings of losing control, and going crazy. Which nursing intervention should be included for the diagnosis of panic disorder? |
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Definition
Convey the etiology and management of panic disorders
Educating a client is one of the essential nursing responsibilities. Discussing the etiology and management of panic disorders begins the process of empowering the client to gain control. |
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Term
| A client has made an appointment to see a primary care provider because of increased anxiety. In teaching the client, which of the following medications would likely be prescribed for anxiety? |
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Definition
Diazepam (Valium)
Diazepam (Valium) is an antianxiety agent. |
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Term
| When caring for a client who is experiencing a panic attack, which nursing action should be implemented? (Select all that apply.) |
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Definition
Reduce stimuli in the immediate environment.
Administer anti-anxiety medication as ordered.
Speak softly to gain client's attention.
Reducing stimuli in the immediate environment helps a client experiencing a panic attack to return to a calmer state. The nurse should administer anti-anxiety medication as ordered for a client experiencing a panic attack. The nurse should speak softly to gain a client's attention. The softer voice will require the client to calm down enough to listen to what is being said. Speaking loudly and forcefully can increase the client's anxiety. A client experiencing a panic attack should not be left alone. |
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Term
| The nurse is planning care for a client with suicidal ideation who will be treated as an outpatient. Which teaching(s) would the nurse provide to the caregivers? (Select all that apply.) |
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Definition
Do not leave client alone.
Establish a no-suicide contract with the client.
Prepare the home environment to be free from substances and firearms.
Caregivers should keep the number of an emergency contact person nearby.
Scheduled counseling appointments daily until the suicidal ideation passes.
For the client treated as an outpatient, it is important to not leave the client alone, establish a no-suicide contract with the client, prepare the home environment to be free from substances and firearms, keep the number of an emergency contact nearby, and schedule counseling appointments daily until the suicidal ideation passes. |
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Term
| A client is to undergo electroconvulsive therapy in the morning. Which nursing intervention is appropriate? |
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Definition
Verify that informed consent has been granted.
Informed consent must be obtained prior to ECT. |
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Term
| In assessing a suicidal risk, which nursing comment is most appropriate? |
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Definition
You seem desperate. Do you have a plan and a lethal means for suicide?
The nurse asked the client a direct question about the intent and lethality. The answer will provide concrete, immediate information and assist the nurse with formulating an appropriate nursing intervention. |
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Term
| When caring for a client with anorexia nervosa, which daily nursing assessment should the nurse complete? |
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Definition
Weight
Weighing the client daily is an important measurement of nutritional status. |
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Term
| A client has lost behavioral control, and is threatening staff and other clients while breaking several windows. Upon being escorted to the seclusion room by security, which statement is most correct when explaining to the client why the nurse must now apply four-point restraints? |
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Definition
This is a means of providing safety for you and everyone else on the unit.
It is important to provide safeguards in order to protect clients who are out of control. The nurse is educating the client in a non-judgmental, objective manner. |
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Term
| A college student presents at the health clinic and tells the nurse that he feels overwhelmed and nervous about upcoming exams. He further reports that he hasn't been able to concentrate while reading textbook assignments and has difficulty paying attention in class. Several times in the last week, he has had to get up and leave class because he felt as though he couldn't breathe and his heart was pounding. The most appropriate nursing diagnosis based on this interview assessment is: |
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Definition
Panic anxiety
The client has reported classic symptoms of a panic level of anxiety: impaired concentration, inability to maintain attention, difficulty breathing, and rapid pulse. |
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Term
| The nurse is preparing to perform an assessment on a newly admitted client who attempted suicide. Which questions would the nurse ask? (Select all that apply.) |
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Definition
How did you attempt to commit suicide?
Do you have any family support?
Have you attempted suicide before?
How have you coped with stress in the past?
It is important for the nurse to assess how the client attempted suicide, whether there is family support available, if the client has attempted suicide in the past, and what coping mechanisms the client has used. These are all important pieces of information to assess for future suicide risk, and to give the nurse insight into planning care. Asking a client why he or she did something encourages defensiveness. |
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Term
| A client has experienced the loss of a child in a traumatic house fire. Which behavior indicates localized amnesia? |
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Definition
Three days later, the client still does not recall the house fire.
This behavior is representative of localized amnesia, which is the inability to recall all incidents associated with the traumatic event for a specific time period following the event (usually a few hours to a few days). |
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Term
| A client has given consent to begin ECT for the treatment of severe depression. The client awakens early, 2 hours before the ECT begins, and asks, Can I please get something to eat? I missed dinner last night because I wasn't feeling well. Which is the appropriate nursing response? |
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Definition
I realize you are very hungry, but you cannot eat before treatment because it can lead to complications.
The client must be NPO before ECT to prevent complications from the anesthesia and treatment. |
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Term
| A client reports an irrational fear of spiders, and avoids them at all costs. In planning care for the client, it is important for the nurse to expect what? |
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Definition
The behavioral style of phobic clients is avoidance.
Persons suffering from phobic behaviors use avoidance. This client avoids [spiders] at all costs. |
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Term
| The nurse is assessing a client for side effects of electroconvulsive therapy (ECT). Which side effects are common and to be expected? (Select all that apply.) |
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Definition
Temporary memory loss
Confusion
Temporary memory loss and confusion are common side effects of ECT. Permanent memory loss, brain damage, and cardiovascular complications are not considered common side effects. |
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Term
| In evaluating learning, the nurse asked the client to answer the following statement: When used in combination with anxiolytic medication, alcohol leads to _____________ effects and caffeine leads to _______________ effects. (Fill in the blanks.) |
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Definition
Increased; decreased
Anxiolytic medications work through depression of certain central nervous system (CNS) functions. Alcohol, which is a CNS depressant, would increase/potentiate their effects. Caffeine, which is a CNS stimulant, would decrease/inhibit their effects. |
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Term
| When establishing a nursing plan of care for an obese client, which one of the following is an appropriate outcome criterion? |
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Definition
Achieving and maintaining weight within normal parameters for size and age
Achieving and maintaining weight within normal parameters for size and age is an identified expected outcome. |
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Term
| A client is admitted to the psychiatric unit diagnosed with depression and an eating disorder, complaining that she has an ugly appearance. She yells at the nurse to do something about it. Which one of the following is the best nursing response? |
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Definition
You seem angry. Tell me what you are feeling.
This response verbalizes the implied and allows the client to express feelings. |
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Term
| Which one of the following statements would indicate to the nurse that a client is experiencing suicidal ideation? |
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Definition
I've had enough. I'm just a burden and I have no other choice but to end my life.
The client clearly states that there are no alternatives to suicide, and has clearly stated that his choice is to end his life. |
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Term
| After the nurse explains ECT to an outpatient client who is scheduled for the first treatment, the client states, I'm too scared and can't decide what to do. Which is the appropriate nursing response? |
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Definition
Tell me more about how you feel.
This therapeutic response explores the client's feelings about fears related to the treatment. |
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Term
| The client has been on haloperidol (Haldol) for 3 days. He tells the nurse that his neck is stiff and his tongue is pulling to one side of his mouth. The nurse concludes that the client is experiencing: |
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Definition
Acute dystonia
The client is exhibiting classic signs of acute dystonia: sudden spasms of the neck and the tongue pulling to one side. |
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Term
| The nurse is caring for a client who is considered to be at risk for suicide. Which client statement would require immediate nursing intervention to promote safety? |
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Definition
My family won't need to worry about me in another day.
This statement indicates that the client has a plan with a determined end, and requires the nurse to immediately provide for safety. |
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Term
| A newly admitted client with antisocial personality disorder is manipulative, cold, and callous, as well as charming and intelligent. What is the most effective nursing intervention for this client? |
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Definition
Discuss behaviors that are acceptable by society.
Discussing behaviors help to promote self-awareness in an effort to help the client gain insight into his or her own behavior. |
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Term
| The physician has ordered lithium carbonate for a bipolar client. The nurse administering the drug determines that the most likely rationale for this drug is to do which of the following? |
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Definition
Decrease hyperactivity
Lithium carbonate enhances reuptake of norepinephrine and serotonin, resulting in decreased hyperactivity. |
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Term
| Drugs used to control anger or diminish anxiety are generally of the _____ class or in some way depress the CNS. |
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Definition
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Term
| Drugs that elevate the mood are called _____. |
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Definition
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Term
| The nurse identifies that the primary nursing goal for a client diagnosed as having anorexia nervosa should be aimed at: |
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Definition
Promoting improved nutrition
Because there is a concern for physiological complications, restoration of adequate nutrition is a primary goal. |
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Term
A nursing home resident began having symptoms of an anxiety attack. The physician ordered alprazolam (Xanax) 0.25 mg bid. On hand were 0.5-mg tablets. How many tablets did the nurse administer? (Fill in the blank.)
Answer: |
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Definition
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Term
| A client admitted for a suicide attempt tells the nurse that her beloved husband died three months ago. Her income is barely enough to sustain her, and she is worried about how she will pay bills. To what does the nurse attribute this client's suicidal crisis? |
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Definition
A precipitating stressor
The client's husband's death 3 months ago can easily be seen as a precipitating stressor, which is a life stress accompanied by an increase in emotional disturbance such as the loss of a loved person either by death or by divorce, problems in major relationships, changes in roles, or serious physical illness. |
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Term
| ______ _____ _______ involve the ability to tolerate losses and disappointments, which are often compromised if those losses and disappointments occur during various stages of life in which the individual struggles with developmental issues (e.g., adolescence, midlife). |
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Definition
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Term
| _____ ______ involves the experience of numerous failures or rejections that would increase a client's vulnerability for a dysfunctional response to the current situation. |
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Definition
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Term
| If an anorectic client is being forced to eat, it is important for the nurse to implement which one of the following interventions? |
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Definition
Observe bathroom behavior
Observing bathroom behavior may be necessary if the nurse suspects that the client is discarding food or purging. |
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Term
| Which nursing actions are appropriate during electroconvulsive therapy (ECT)? |
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Definition
Ensure patency of airway. Provide suctioning if needed.
Assist anesthesiologist with oxygenation as required.
Observe readouts on machines monitoring vital signs and cardiac functioning.
Provide support to the client's arms and legs during the seizure.
Observe and record the type and amount of movement induced by the seizure. |
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Term
| A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, the family describes the client as being on the move, sleeping 3 to 4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, which response would the nurse expect? |
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Definition
A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, the family describes the client as being on the move, sleeping 3 to 4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, which response would the nurse expect?
Grandiosity and an inflated sense of self-worth are characteristic of this disorder. The client's behavior reflects grandiosity by being on the move, spending excessively, not sleeping, and losing weight (likely due to activity, and forgetting to eat). |
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Term
| The nurse is caring for a 62-year-old client who attempted suicide. The client was a business executive, and had just been fired from his job. He feels that he is nothing without a prominent position at his law firm. Which theoretical perspective about suicidal risk does the nurse recognize? |
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Definition
Shame and humiliation
The client is experiencing shame and humiliation that goes with the loss of a job. Suicide is then seen as a face-saving mechanisma way to prevent public humiliation following a social defeat such as a sudden loss of status or income. Often these individuals are too embarrassed to seek treatment or other support systems. |
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Term
| Which one of the following interventions should the nurse include when planning care for a client diagnosed with histrionic personality disorder? |
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Definition
Set firm limits on attention-seeking behaviors.
These persons need to be the center of attention. Setting and enforcing limits is essential in promoting adaptive behaviors. |
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Term
| In evaluating the success of care and to determine if the person diagnosed as having an eating disorder is ready for discharge, the nurse should ask which one of the following questions? |
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Definition
Is success inadequately measured?
Continually evaluating goals encourages the nurse to adequately measure the client's success. |
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Term
| The nurse includes medication education in the discharge plans for a client diagnosed with bipolar disorder who is taking lithium carbonate. Which teaching should the nurse plan to include? |
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Definition
Do not skimp on dietary sodium intake.
It is important for the client to consume sufficient sodium in the diet because sodium depletion will decrease renal excretion of lithium and cause the drug to accumulate in the body. |
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Term
A client was admitted to the local mental health unit with symptoms of chronic alcoholism. The physician ordered disulfiram (Antabuse) 375 mg PO. On hand were 250-mg tablets. How many tablets did the nurse administer? (Fill in the blank.)
Answer: |
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Definition
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Term
| The nurse, working with a client who has been diagnosed as having bulimia nervosa and who has frequent episodes of binging and purging, needs to consider that this disorder is subject to which? |
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Definition
A mood disorder
Persons who suffer from binging and purging are subject to mood disorders, anxiety disorders, substance abuse or dependence. |
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Term
| A client has been married and divorced four times, and is now admitted to the psychiatric unit with a diagnosis of borderline personality disorder. The nurse expects which of the following behavior patterns would be evident with borderline personality disorder? |
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Definition
Emotional instability
People with borderline personality disorder have affective lability. Their moods shift frequently. |
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Term
| A client has been diagnosed with body dysmorphic disorder (BDD). Which presentation does the nurse anticipate? |
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Definition
The client has a fear of physical defect, but appears normal.
While the individual appears normal to others, he or she has an excessive concern and fear that the body is deformed or defective in some specific way. |
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Term
| A client who is narcissistic and shows little regard for peers and the hospital staff is preoccupied with fantasies of success, power, and intelligence. Which reflects the best nursing intervention? |
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Definition
Discuss the unrealistic sense of entitlement.
One diagnostic criterion for the narcissistic personality disorder is a sense of entitlement. These clients show an arrogant attitude based on feelings of entitlement and envy. Discussion of the behavior may help the client work through feelings of reasonable expectations of especially favorable treatment. |
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Term
| The nurse is caring for four clients. Based on knowledge and statistics associated with suicidal risk, which client does the nurse recognize as more predisposed to a suicide attempt? |
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Definition
15-year-old male who abuses substances
Adolescence is a prime age for suicidal attempts, especially among males and someone who abuses substances. . It is the third leading cause of death in this age group. |
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Term
| The borderline client becomes restless and disruptive during group therapy every afternoon, even attempting to manipulate and undermine the nurse therapist. Which statement reflects a therapeutic response by the nurse? |
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Definition
Let's see if anyone else in the room has had similar feelings and behavior and how they learned to deal with them.
This response places necessary limits without threatening the client but redirects the flow of conversation to include other clients. It also validates what the client may be experiencing. |
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Term
| A client with a diagnosis of bipolar disorder has been hospitalized for a number of weeks and asks the nurse, Do you think that the doctor is ever going to discharge me? Which is the appropriate nursing response? |
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Definition
Tell me more about your feelings about being hospitalized.
This response explores the client's feelings about the length of stay and allows the client to self-pace the information. |
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Term
| A client is discussing his pending divorce, stating he has been married for 30 years and doesn't want the divorce. During the assessment, the nurse learns that the client is suffering from insomnia, anorexia, a feeling of insecurity, and has a history of suicidal gestures. Which therapeutic statement by the nurse is most supportive? |
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Definition
I can see that you are upset. This is a difficult time for you.
The use of reflection of feelings signifies understanding, empathy, and respect for the client. |
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Term
| A client experiencing anxiety reaction is admitted to an inpatient psychiatric unit. While adjusting to the daily routine on the unit, the nurse would like the client to concentrate on completing tasks. Which nursing action would be most appropriate to accomplish this goal? |
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Definition
Assess the cause of anxiety.
Assessing the cause of the client's anxiety is an important part of the nursing plan. A plan of care cannot be effectively established without understanding the cause of anxiety. Both the client and the nurse need to work together to establish a plan. |
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Term
| A client continues to ring the call bell incessantly. Which nursing action reflects classical conditioning? |
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Definition
Answering the bell each time it is rung
Answering the bell each time it is rung reflects a type of classical conditioning. |
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Term
| When planning care for a client diagnosed with bulimia nervosa, which is the priority nursing intervention? |
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Definition
Stay with client during established mealtimes.
Staying with a client during established time for meals helps reduce anxiety around mealtimes. It also allows the nurse to monitor the client for possible purging. |
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Term
| The nurse is leading a weight loss group for morbidly obese people. Which teaching should the nurse include? (Select all that apply.) |
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Definition
Keep a food diary.
Learn alternate ways to handle stress.
The nurse should teach a group of morbidly obese people to keep a food diary. This will help the clients see exactly what types of foods they are eating and how much. The nurse should also teach alternate ways to handle stress. These methods can be called upon when the client feels the desire to overeat. The nurse should teach a group of morbidly obese people to focus on physical activity rather than food intake. The nurse should teach a group of morbidly obese people to lose 1 to 2 pounds weekly and to eat three meals and two snacks during the day. Avoiding food throughout the day increases the chance of overeating when the client becomes extremely hungry. |
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Term
| A client who is 5'4'' weighs 250 pounds. When she first came to the clinic 2 years ago, she weighed 347 pounds. After being weaned from diet pills, the client says to the nurse, I don't know what to do! I know I can't lose weight without those drugs. The nurse tells the client that she will lose weight even without medication if she just sticks to her diet and adds some exercise to her routine. What kind of exercise should the nurse review with the client? |
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Definition
Walking around her neighborhood for 20 minutes per day (weather permitting)
This exercise is within the client's capabilities and easy to perform every day. It would not cost any extra money. This will increase the likelihood that she would do it. |
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Term
| The nurse determines that clients diagnosed with anorexia nervosa exhibit which trait? |
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Definition
Need to control one aspect of their lives
Anorectic persons thrive on self-control through their weight and diet. |
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Term
| When planning short-term goals for a client diagnosed as having an eating disorder and who expresses emotional conflicts in a destructive manner, the nurse would consider which one of the following? |
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Definition
Adaptive coping skills
After the client's strengths and adaptive coping skills have been identified, short-term goals can be established. |
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Term
The physician orders clomipramine (Anafranil) 75 mg HS to a nursing home resident for OCD. On hand were 50-mg tablets. The nurse administered how many tablets? (Fill in the blank.)
Answer: |
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Definition
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Term
| A client who has been hospitalized for mania in the past maintains stability with medication. Recently the client has been laid off from a job, and has become depressed. The client is found unconscious, but still breathing, with an empty bottle of sertraline nearby. After stabilization in the emergency department, the client is transferred to the psychiatric unit with a diagnosis of bipolar I disorder, current episode depressed. Which would the nurse determine as the rationale for this diagnosis, as opposed to major depression? |
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Definition
The client has experienced a manic episode in the past.
The client's past history of mania supports the diagnosis of bipolar I disorder, current episode depressed. |
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Term
| A client who has been hospitalized for mania in the past maintains stability with medication. Recently the client has been laid off from a job, and has become depressed. The client is found unconscious, but still breathing, with an empty bottle of sertraline nearby. After stabilization in the emergency department, the client is transferred to the psychiatric unit with a diagnosis of bipolar I disorder, current episode depressed. Which would the nurse determine as the rationale for this diagnosis, as opposed to major depression? |
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Definition
The client has experienced a manic episode in the past.
The client's past history of mania supports the diagnosis of bipolar I disorder, current episode depressed. |
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Term
| Which is the most effective nursing intervention to assist a client experiencing moderate anxiety? |
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Definition
Explore the cause.
Exploring the cause of anxiety is recommended only if the client is experiencing mild or well-controlled anxiety. In the state of experiencing moderate anxiety, the client's perceptual field has narrowed, and he or she is unlikely to be able to discuss the cause of anxiety rationally. |
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Term
| The nurse is caring for a client who attempted suicide. The client served in Desert Storm and has been diagnosed with Posttraumatic Stress Disorder. His friends were all killed in the war, and he survived; he now feels horrible that he lived and they died. Which theoretical perspective about suicidal risk does the nurse recognize? |
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Definition
Desperation and guilt
With desperation, an individual feels helpless to change, but he or she also feels that life is impossible without such change. Guilt and self-recrimination are other aspects of desperation. These affective components were found to be prominent in Vietnam veterans with posttraumatic stress disorder exhibiting suicidal behaviors. |
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Term
| In the posttreatment period after electroconvulsive therapy (ECT), which is an appropriate nursing intervention? |
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Definition
Orient client to time and place.
Orienting the client to time and place helps him or her to regain a sense of reality following ECT. |
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Term
| The nurse must be alert to nonverbal expressions. Because the meaning attached to nonverbal behavior is subjective, which should the nurse do? |
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Definition
Validate its meaning.
The nurse should always validate the meaning and significance of a specific behavior. |
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Term
| A client is being discharged from the inpatient psychiatric unit after a 4-day stay. She was admitted with major depression that was a single episode and moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg PO qd. The nurse's discharge teaching should include which? (Select all that apply.) |
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Definition
Continue taking Prozac as prescribed. You will continue to see improvement over the next few weeks.
Make sure that you follow up with outpatient psychotherapy as has been arranged.
You may be able to discontinue the medication within 6 months to 1 year, but only under a doctor's supervision. However, there is a chance of recurring episodes.
Continued improvement may be seen in
the first few weeks of treatment with fluoxetine, as the therapeutic effect can take up to 4 weeks to be realized. Compliance with follow-up psychotherapy should be stressed so that the client does not expect the medication to be the only treatment. Although the medication may be tapered and stopped after 6 months, there is a risk for further depressive episodes. The client should avoid foods with tyramine if she were taking an MAOI, not an SSRI antidepressant such as fluoxetine. The medication should not be stopped abruptly because of the risk for further depressive episodes. |
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Term
| The client asks the nurse what is involved with electroconvulsive therapy (ECT). What is the appropriate client teaching? (Select all that apply.) |
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Definition
It creates a seizure in the brain.
It involves placing electrodes on your head.
You will get a muscle relaxant before the treatment.
Appropriate client teaching includes explaining ECT as a created seizure in the brain, involving placement of electrodes on the head, and describing the muscle relaxant received before treatment. Most clients need 6 to 12 treatments. It is not appropriate to tell the client to not have the procedure done, as the client must decide this for him- or herself after being given informed consent. |
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Term
A client develops a generalized rash secondary to severe anxiety. The physician orders hydroxyzine (Atarax) 75 mg tid for the itching. Using a 50 mg/mL vial, how many milliliters did the nurse administer? (Fill in the blank.)
Answer: |
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Definition
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Term
| The nursing care plan for a client diagnosed with OCD should include which one of the following interventions? |
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Definition
Explore activities that are pleasurable.
For persons diagnosed with OCD, work organizes their lives at the exclusion of pleasure. A therapeutic approach should include attempting to identify pleasurable activities to gradually reintroduce. |
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Term
| Which evaluation of the suicidal client would indicate to the nurse that further intervention is required? |
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Definition
The client feels unaccepted by certain people.
This evaluation indicates that the client still has unresolved issues that require further intervention. |
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Term
| A client admitted with an eating disorder complains to the nurse in a hostile manner that she wants to be discharged because she has been hospitalized for too long. Which is the most appropriate nursing response? |
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Definition
You seem upset. Tell me how you are feeling right now.
The nurse is offering self and acknowledging the client's feelings. |
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Term
| An adolescent suffers from anorexia nervosa. She recently collapsed during cheerleading practice and was hospitalized for severe malnutrition. Her treatment team is planning to use behavior modification. The nurse considers this modality to have which characteristic? |
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Definition
The client collaborates in developing a system of rewards for adaptive behaviors and ultimately decides whether to follow the plan or not.
Because control issues are central to the etiology of eating disorders, behavioral modification programs such as contracting are used to assist the client in gaining control over her maladaptive behaviors. (However, the client is instructed that if her nutritional condition deteriorates, tube feedings will be instituted to protect her from a life-threatening situation.) |
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Term
| Anorexia nervosa, or restrictive eating, is characterized by deliberate starvation. The nurse understands that which of the following features is central to the diagnosis? |
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Definition
Body image disturbance
Persons diagnosed with anorexia nervosa exhibit an intense fear of gaining weight. They deny being thin even when grossly underweight and will refer to self as being too fat. |
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Term
| A client with a diagnosis of borderline personality disorder is admitted to the mental health unit because of a suicide attempt, anxiety, and depression. Which of the following actions taken by the nurse reflects understanding of this disorder? |
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Definition
Start supportive counseling to identify the source of anger, thus reducing potential staff countertransference and conflict.
The client with a borderline personality disorder often displaces negative feelings onto the staff, resulting in countertransference. The client will also engage in behaviors to split the staff, which could cause conflict. |
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Term
| A client returns to the psychiatric unit from ECT. The nurse anticipates that which of the following is a projected outcome of ECT? |
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Definition
The client's mood will be elevated.
ECT is effective with clients who are in treatment for severe depression. The treatment should yield results that are positive. |
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Term
| A client experienced a severe psychic trauma 1 month ago and developed paralysis of the lower extremities. Which of the following is the priority nursing intervention? |
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Definition
Assess the client for organic causes of paralysis.
The first priority is to rule out organic factors for the paralysis. Once this has been identified, a plan of care can be effectively established. |
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Term
| Since starting college, a client has been unrealistically worried about his academic performance as well as his relationship with his girlfriend. He cannot sleep or concentrate because he cannot stop worrying about the numerous papers and assignments that are due over the course of the semester. He is irritable and on edge. The nurse expects this behavior to be associated with which condition? |
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Definition
Generalized anxiety disorder.
Generalized anxiety disorder is characterized by chronic, unrealistic, and excessive anxiety and worry. This describes the client's symptoms in this scenario. |
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Term
| A client weighing 450 pounds, confides in the nurse that she was sexually molested by her father as a young child. She believes her mother knew about the abuse, yet did not act to protect the client. The nurse considers that obesity is thought to represent: |
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Definition
A relationship with mother
Overeating is common in people rejected by mothers so they seek the good mother image in food. The symptoms of obesity are viewed as depressive equivalents, attempts to regain lost or frustrated nurturance and caring. |
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Term
| A client presents to the mental health clinic stating that she is concerned about her bizarre eating behavior. During the nursing assessment, the client states that she has a history of gorging and purging. The nurse observes that the client has dental enamel erosion and calluses on the knuckles. Which one of the following assessments would be most helpful when developing a plan of care? |
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Definition
Eating patterns of the family
The environment within the family structure is often marked by chaos and conflict, which triggers inner conflicts and self-defeating behaviors. |
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Term
| A client is diagnosed with posttraumatic stress disorder (PTSD) after undergoing a complete diagnostic work-up. What must the nurse understand about the physical symptoms of PTSD before planning care? |
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Definition
The symptoms are a mechanism to help the client cope with an unacceptable situation.
Physical symptoms are a defense mechanism that absorbs and neutralizes the anxiety generated by unacceptable, unconscious impulses. |
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Term
| A client is discussing her suicide attempt with the nurse. Which nursing response is appropriate? |
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Definition
Can you think of circumstances in which you feel in control?
This response is therapeutic, as it allows the client to reflect on things in her world that she feels are within her control. It is important for the client to feel some control over his or her life situation in order to perceive a measure of self-worth. |
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Term
| The nurse is evaluating care for a client with disturbed personal identity. Which outcome would indicate that nursing interventions have been effective? |
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Definition
The client understands reason for each personality's existence.
Client recognition of the significance of each personality demonstrates that interventions have been effective. |
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Term
| A client diagnosed with borderline personality disorder called her attorney, reporting client abuse and being held hostage. The nurse considers that this is an example of what? |
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Definition
A client diagnosed with borderline personality disorder called her attorney, reporting client abuse and being held hostage. The nurse considers that this is an example of what?
Privileged communication is the right of all clients to discuss information with their attorney. The client has chosen to make the call and share this information; therefore, it is privileged. |
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Term
| A college student was admitted to the psychiatric unit because of an eating disorder. During the nursing assessment, the client stated that she was depressed over her social life and weight problems. She mentioned that she has numerous episodes of purging. The nurse expects the physician to make which one of the following diagnoses? |
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Definition
Bulimia nervosa
Persons with bulimia nervosa frequently eat large amounts of food and then purge themselves. Purging is one criterion for bulimia nervosa. |
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Term
| A client has a diagnosis of bipolar disorder. Which medication would the nurse anticipate to be ordered? |
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Definition
Lithium carbonate (Eskalith)
Lithium carbonate is the drug of choice for maintenance therapy in clients diagnosed as having a bipolar disorder. It reduces the hyperactivity that is characteristic of the disorder. |
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Term
| __________ is an antipsychotic agent prescribed for schizophrenia and related psychosis, but not bipolar disorder. |
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Definition
|
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Term
| __________ is an antipsychotic used in the management of severely ill persons with schizophrenia, not bipolar disorder. |
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Definition
|
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Term
| ___________ is indicated for anxiety disorders. |
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Definition
|
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Term
| The nurse determines which of the following will give the client the most immediate relief from extrapyramidal side effects of neuroleptics? |
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Definition
Benztropine (Cogentin) 1 mg IM
Cogentin parenterally is the drug of choice for this client. It is the first-line choice of drugs for extrapyramidal symptoms associated with the use of neuroleptics. |
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Term
| The nurse is preparing to perform an assessment on a newly admitted client who is considered a suicide risk. Which questions would the nurse ask? (Select all that apply.) |
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Definition
The nurse is preparing to perform an assessment on a newly admitted client who is considered a suicide risk. Which questions would the nurse ask? (Select all that apply.)
What kind of work do you do?
Do you keep firearms in the house?
Do you have a particular faith that is important to you?
Has anyone in your family attempted suicide?
It is important to know if the client is in a relationship, as single people are more predisposed to suicide attempts. Individuals in the health care professions and business executives are at the highest risk for suicide. Keeping firearms in the house presents a significantly higher risk for suicide than overdosing on substances. Individuals with a faith affiliation are less likely to attempt suicide than those who do not subscribe to a particular faith. A family history of suicide increases risk. |
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Term
| A client demonstrating manic behavior has become demanding and active. The nurse's major objective should include which action? |
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Definition
Maintain a supportive, structured environment, setting limits as necessary in a firm but nonthreatening manner.
The client is having difficulty controlling his behaviors. The nurse must help the client to do so objectively without getting into power struggles. |
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Term
| A new client in the psychiatric unit has a diagnosis of obsessivecompulsive disorder (OCD). On admittance to the unit, the client begins to unpack. Forty-five minutes later, the nurse witnesses the client still folding and unfolding clothes, and arranging and rearranging them in the drawers. Which rationale explains the client's actions? |
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Definition
It relieves anxiety.
Most clients with OCD perform their rituals because it temporarily decreases their anxiety. |
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Term
| A client is scheduled for ECT. Before the client's ECT treatment, what teaching point should the nurse plan to share with the client? |
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Definition
A general anesthesia, with the use of a muscle relaxant drug, is used during the treatment.
According to the American Psychiatric Association standards, ECT should be given under general anesthesia with the use of a muscle relaxant drug. |
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Term
| The nurse is planning on working on crisis counseling with a suicidal client. What is the nurse's priority intervention? |
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Definition
Focus on the current crisis and how it can be alleviated.
Focusing on the current crisis and how it can be alleviated is the priority nursing intervention. Without working through the current crisis, the client cannot effectively move onto other portions of the counseling process. |
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Term
A client is being treated with prazepam (Centrax) 20 mg HS for anxiety. How many 5-mg capsules must the nurse administer? (Fill in the blank.)
Answer: |
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Definition
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Term
The physician ordered amitriptyline (Elavil) 50 mg HS to a nursing home resident for major depression. On hand were 25-mg tablets. The nurse instructed the client to take how many tablets? (Fill in the blank.)
Answer: |
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Definition
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Term
| As the anorectic client's physical condition improves, it is important for the nurse to focus on which characteristic? |
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Definition
Self-determination
As the client begins to feel better about self, the need for unrealistic achievement should diminish. |
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Term
| The nurse is caring for four clients. Which client should not be considered a candidate for electroconvulsive therapy (ECT)? |
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Definition
Client with increased intracranial pressure
The only absolute contraindication for ECT is increased intracranial pressure (from brain tumor, recent cardiovascular accident, or other cerebrovascular lesion). |
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Term
| The nurse is working with the family of a suicidal client. What teaching would the nurse provide? (Select all that apply.) |
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Definition
Take any hint of suicide seriously.
Attempt to remove children of the client from the home.
It is critical to take any hint of suicide seriously. Anyone expressing suicidal feelings needs immediate intervention and attention. If there are children present, it is important to try to remove them from the home. Perhaps another friend or relative can assist by taking them to their home. This type of situation can be extremely traumatic for children. Allowing a suicidal client to confide secretly in an individual is inappropriate. The family should never promise to keep secrets about the client's feelings of suicide. It is important to allow the client to express feelings, even if the family does not agree with the client's self-assessment. Families should be good listeners, let the clients know they are there for them, and be willing to help them seek professional help. It is important that the family does not judge a suicidal person, show anger toward them, provoke guilt in them, discount their feelings, or tell them to snap out of it. This is a very real and serious situation to suicidal individuals. They are in real pain. They feel the situation is hopeless and that there is no other way to resolve it aside from taking their own life. |
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Term
| Which symptom would the nurse expect to see if a mentally ill client is having severe anxiety? |
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Definition
A narrowed perceptual field and decreased attention span
Sensory perception is greatly reduced, making concentration difficult, and there may be a decompensation of ego functions. |
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Term
| Which of the following statements is correct concerning personality disorders? |
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Definition
Personality disorders are a variant of character traits that go beyond the range found in most people.
Personality and character traits are stable and predictable following early adolescence but can become exaggerated to the point that they cause significant functional impairment and subjective distress when a personality disorder emerges. |
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Term
| The nurse is caring for a client who was a victim of a very recent hurricane disaster. Which dissociative disorder would the nurse anticipate? |
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Definition
Dissociative fugue
Dissociative fugue is rare and occurs most often under conditions of war, natural disasters, or intense psychosocial stress. |
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Term
| The physician has written orders for medication to be given to a client with somatoform pain disorder. Which medication would the nurse consider to be least helpful to the client? |
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Definition
Paroxetine (Paxil)
Selective serotonin reuptake inhibitors (SSRIs) have been found to be somewhat less efficacious in analgesic effect than the tricyclics with which they were compared. Paroxetine (Paxil) is an SSRI. |
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Term
| Anursing instruction is teaching about the cause of mood disorders. Which statement best indicates an understanding of teh etiology of mood disorders? |
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Definition
| Evidence supports multiple causations |
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Term
| A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms? |
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Definition
| "Became irritable and agitated on waking" |
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Term
| Wich symptom is an example of physiological alterationsexhibited by clients diagnosed with moderate depression? |
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Definition
|
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Term
| Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression? |
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Definition
|
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Term
| Which statement describes a major difference between a client diagnosed with major depressive disorder and a client with dysthymic disorder? A client with dysthymic disorder... |
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Definition
| had symptoms for at least 2 years |
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Term
| A client is admitted with a diagnosis of major depressive disorder. Which of the following data would the nurse expect to assess? |
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Definition
1. Loss of interest in almost all activities
2. A change in more than 5% of body weight in one month
3. psychomotor retardation or agitation
4. Insomina or hypersomnia |
|
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Term
| Major depressiv edisorder would be most difficult to detect in? |
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Definition
| a 13 year old boy (teenager) |
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Term
| A client with major depressive disorder has a nursing diagnosis of low self-esteem r/t negative view of self. Which cognitive intervention by the nurse would be appropriate to deal with this clients problem? |
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Definition
| focus on strengths and accomplishments to minimize failure |
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Term
| A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be most appropriate to implement initially, when establishing nurse-client relationship? |
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Definition
| sit with client and offer self frequently |
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Term
| Which symptom is unique to SAD vs. non-seasonal depression |
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Definition
| Remission of symptoms in spring/summer |
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Term
| In the treatment of SAD, which has the longest effects after being discontinued? |
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Definition
| Cognitive behavioral therapy |
|
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Term
| What is the typical amount of bright light therapy for SAD? |
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Definition
| 10,000 lux for 30 minutes each morning |
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Term
| A client diagnosed with major depressive disorder is being considered for ECT. Which client teaching should the nurse prioritize? |
|
Definition
| Discuss with the client and family expected short term memory loss |
|
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Term
| Which meds would be administered prior to ECT? |
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Definition
Glycopyrrolate (Robinol)
Thiopental sodium (Pentothal)
Succinylcholine chloride (Anectine) |
|
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Term
| Which statement about the development of bipolar disorder is from a biochemincal perspective? |
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Definition
| In bipolar disorder, there may be alterations in normal electrolyte transfer across cell membranes, resulting in increased levels of intracellular calcium and sodium. |
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Term
| A provocatively dressed client with a diagnosis of bipolar 1 disorder is observed laughing loudly with peers in the milieu. Which nursing action is priority in this situation? |
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Definition
| Privately discuss with the client the inappropriateness of provocative dress during the hospitalization. |
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Term
| A client with bipolar 1 disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? |
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Definition
| Calmly redirect and remove the client from the milieu. |
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Term
| A client newly admitted with bipolar 1 disorder has a nursing diagnosis of risk for injury r/t extreme hyperactivity. Which nursing intervention is appropriate? |
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Definition
| Use PRN antipsychoitic medications as ordered. |
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Term
| A nurse working with a client diagnosed with bipolar 1 disorder attempts to recognize the motiviation behind teh client's use of grandiosity. Which is the rationale for this nurses action |
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Definition
| Understanding the reason behind the bahavior would assist the nurse to accept and relate to the client, not the behavior. |
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Term
| A nursing instructior is teaching about the criteria for the diagnosis of bipolar II disorder. Which statement indicates that learning has occurred? Clients with bipolar II disorder: |
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Definition
| Experience recurrent bouts of depression with episodic occurrences of hypomania. |
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Term
| A nurs on an in-patient psychiatric unit recieves report at 1500 hours. Which client would need to be assessed first? |
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Definition
| a client pacing the hall and experiencing irritability and flight of ideas |
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Term
| A client experiencing mania states "Everything I do is great" Using a cognitive approach, which nursing response would be most appropriate? |
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Definition
| "Is there a time in your life when things didn't go as planned?" |
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Term
| Aclient taking lithium carbonate is experiencing an excessive output of dilute urine, tremors, and muscular irritability. THe client's lithium level would most likely be which of the following? |
|
Definition
| 2.6 mEq/L (normal is 0.6-1.2) |
|
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Term
| Which staement is true about suicide? |
|
Definition
Almost 95% of all people who commit suicide or attempt suicide have a diagnosed mental (mood) disorder.
Depressive disorders account for 80% of all individuals who commit or attempt to commit suicide. |
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Term
| The nurse in the ED is assessng a client suspected of being suicidal. WHat is the first most critical question that the nurse should ask? |
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Definition
| "Are you currently thinking about suicide?" |
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