4 The Nursing Care of Clients with Psychiatric Disorders and Mental Health Problems Flashcards

Question 1

Q

The Client with Major Depression
1. The nurse is planning care with a Mexican client who is diagnosed with depression. The client
believes in “mal ojo” (the evil eye) and uses treatment by a root healer. The nurse should do which of
the following?
1. Avoid talking to the client about the root healer.
2. Explain to the client that Western medicine has a scientific, not mystical, basis.
3. Explain that such beliefs are superstitious and should be forgotten.
4. Involve the root healer in a consultation with the client, primary health care provider, and
nurse.

Answer

A

The Client with Major Depression
1. 4. Including the root healer gives credibility and respect to the client’s cultural beliefs.
Avoiding talking about the healer demonstrates either ignorance or disregard for the client’s cultural
values. Negative comparison of root healing with Western medicine not only denigrates the client’s
beliefs but is likely to alienate and cause the client to end treatment.
CN: Psychosocial integrity; CL: Create

Question 2

Q

After a period of unsuccessful treatment with Elavil (amitriptyline), a woman diagnosed with
depression is switched to Parnate (tranylcypromine). Which statement by the client indicates the
client understands the side effects of Parnate?
“I need to increase my intake of sodium.”
“I must refrain from strenuous exercise.”
“I must refrain from eating aged cheese or yeast products.”
“I should decrease my intake of foods containing sugar.”

Answer

A

1. Cheese and yeast products contain tyramine which the client should avoid to prevent a
  negative interaction with Parnate, a monoamine oxidase (MAO) inhibitor. Sodium will not interact
  with Parnate and neither exercise nor sugar needs to be limited.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 3

Q

A client is scheduled for the first electroconvulsive therapy (ECT) treatment in the morning.
The client has been unable to sleep but at 10 PM refused to take Restoril as the nurse suggested. The
client is still unable to sleep at 11:15 PM . In what order should the nurse do the following?
Sit quietly with the client.
Encourage the use of Restoril.
Offer use of MP3 player with relaxing music.
Discuss specific concerns.

Answer

A

3.
1. Sit quietly with the client.
4. Discuss specific concerns.
3. Offer use of MP3 player with relaxing music.
2. Encourage the use of Restoril.
The client is likely anxious about the procedure. The nurse should first spend time with the client
and then discuss the client’s concerns about the procedure. Next, the nurse could suggest the client
listen to relaxing music. The use of the sleeping medication would only be considered as a last resort
since it might interfere with the effectiveness of the seizure required for the treatment.
CN: Psychosocial integrity; CL: Synthesize

Question 4

Q

The client is receiving 6 mg of selegiline transdermal system every 24 hours for major
depression. The nurse should judge teaching about Emsam to be effective when the client makes
which statement?
“I need to avoid using the sauna at the gym.”
“I can cut the patch and use a smaller piece.”3. “I need to wait until the next day to put on a new patch if it falls off.”
“I might gain at least 10 lb (4.5 kg) from the medication.”

Answer

A

1. Selegiline transdermal system is the first transdermal monoamine oxidase inhibitor. The
  client needs to avoid exposing the application site to external sources of direct heat, such as saunas,
  heating lamps, electric blankets, heating pads, heated water beds, and prolonged direct sunlight
  because heat increases the amount of selegiline that is absorbed, resulting in elevated serum levels of
  selegiline. Cutting the patch and using a smaller piece will result in a decreased amount of medicationabsorption, most likely leading to a worsening of the symptoms of depression. The client should
  apply a new patch as soon as possible if one falls off to ensure an adequate amount of medication
  absorption. Selegiline is not associated with significant weight gain, although a weight gain of 1 to 2
  lb (2.2 to 4.4 kg) is possible.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 5

Q

A client has been taking 30 mg of duloxetine hydrochloride (Cymbalta) twice daily for 2
months because of depression and vague aches and pains. While interacting with the nurse, the client
discloses a pattern of drinking a six-pack of beer daily for the past 10 years to help with sleep. What
should the nurse do first?
Refer the client to the dual diagnosis program at the clinic.
Share the information at the next interdisciplinary treatment conference.
Report the client’s beer consumption to the primary health care provider.
Teach the client relaxation exercises to perform before bedtime

Answer

A

1. The nurse should report the client’s beer consumption to the primary health care provider.
  Duloxetine should not be administered to a client with renal or hepatic insufficiency because the
  medication can elevate liver enzymes and, together with substantial alcohol use, can cause liver
  injury. Referring the client to the dual diagnosis program, sharing information at the next
  interdisciplinary treatment conference, and teaching the client relaxation exercises are helpful
  interventions for the nurse to implement. However, reporting the findings to the primary health care
  provider is most important.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 6

Q

A client was admitted to the inpatient unit 3 days ago with a flat affect, psychomotor
retardation, anorexia, hopelessness, and suicidal ideation. The primary health care provider
prescribed 75 mg of venlafaxine extended release (Effexor XR) to be given every morning. The client
interacted minimally with the staff and spent most of the day in his room. As the nurse enters the unit
at the beginning of the evening shift, the client is smiling and cheerful and appears to be relaxed. What
should the nurse interpret as the most likely cause of the client’s behavior?
The Effexor is helping the client’s symptoms of depression significantly.
The client’s sudden improvement calls for close observation by the staff.
The staff can decrease their observation of the client.
The client is nearing discharge due to the improvement of his symptoms.

Answer

A

1. The client’s sudden improvement and decrease in anxiety most likely indicate that the client
  is relieved because he has made the decision to kill himself and may now have the energy to complete
  the suicide. Symptoms of severe depression do not suddenly abate because most antidepressants work
  slowly and take 2 to 4 weeks to provide a maximum benefit. The client will improve slowly due to
  the medication. The sudden improvement in symptoms does not mean the client is nearing discharge
  and decreasing observation of the client compromises the client’s safety.
  CN: Psychosocial adaptation; CL: Analyze

Question 7

Q

The client is taking 50 mg of lamotrigine (Lamictal) daily for bipolar depression. The client
shows the nurse a rash on his arm. What should the nurse do?
Report the rash to the primary health care provider.
Explain that the rash is a temporary adverse effect.
Give the client an ice pack for his arm.
Question the client about recent sun exposure.

Answer

A

1. The nurse should immediately report the rash to the primary health care provider because
  lamotrigine can cause Stevens-Johnson syndrome, a toxic epidermal necrolysis. The rash is not a
  temporary adverse effect. Giving the client an ice pack and questioning the client about recent sun
  exposure are irresponsible nursing actions because of the possible seriousness of the rash.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 8

Q

The nurse is reviewing the laboratory report with the client’s lithium level taken that morning
prior to administering the 5 PM dose of lithium. The lithium level is 1.8 mEq/L (1.8 mmol/L). The
nurse should:
Administer the 5 PM dose of lithium.
Hold the 5 PM dose of lithium.
Give the client 8 oz (236 mL) of water with the lithium.
Give the lithium after the client’s supper.

Answer

A

1. The nurse should hold the 5 PM dose of lithium because a level of 1.8 mEq/L (1.8 mmol/L)
  can cause adverse reactions, including diarrhea, vomiting, drowsiness, muscle weakness, and lack of
  coordination, which are early signs of lithium toxicity. The nurse should report the lithium level to the
  primary health care provider, including any symptoms of toxicity. Administering the 5 PM dose of
  lithium, giving the client the lithium with 8 oz (236 mL) of water, or giving it after supper would
  result in an increase of the lithium level, thus increasing the risk of lithium toxicity.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 9

Q

A nurse is conducting a psychoeducational group for family members of clients hospitalized
with depression. Which family member’s statement indicates a need for additional teaching?
“My husband will slowly feel better as his medicine takes effect over the next 2 to 4 weeks.”
“My wife will need to take her antidepressant medicine and go to group to stay well.”
“My son will only need to attend outpatient appointments when he starts to feel depressed again.”
“My mother might need help with grocery shopping, cooking, and cleaning for a while.”

Answer

A

1. Additional teaching is needed for the family member who states her son will only need to
  attend outpatient appointments when he starts to feel depressed again. Compliance with medication
  and outpatient follow-up are key in preventing relapse and rehospitalization. The statements
  expressing expectations of feeling better as medication takes effect, needing medicine and group
  therapy to stay well, and needing help with grocery shopping, cooking, and cleaning for a while
  indicate the families’ understanding of depression, medication, and follow-up care.
  CN: Psychosocial integrity; CL: Evaluate

Question 10

Q

A 16-year-old client is prescribed 10 mg of paroxetine (Paxil) at bedtime for major
depression. The nurse should instruct the client and parents to monitor the client closely for which
adverse effect?1. Headache.
Nausea.
Fatigue.
Agitation.

Answer

A

1. The nurse closely monitors the client taking paroxetine for the development of agitation,
  which could lead to self-harm in the form of a suicide attempt. Headache, nausea, and fatigue aretransient adverse effects of paroxetine.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 11

Q

A client diagnosed with major depression spends most of the day lying in bed with the sheet
pulled over his head. Which of the following approaches by the nurse is most therapeutic?
Wait for the client to begin the conversation.
Initiate contact with the client frequently.
Sit outside the client’s room.
Question the client until the client responds.

Answer

A

1. The nurse should initiate brief, frequent contacts throughout the day to let the client know
  that he is important to the nurse. This will positively affect the client’s self-esteem. The nurse’s action
  conveys acceptance of the client as a worthwhile person and provides some structure to the seemingly
  monotonous day. Waiting for the client to begin the conversation with the nurse is not helpful because
  the depressed client resists interaction and involvement with others. Sitting outside of the client’s
  room is not productive and not necessary in this situation. If the client were actively suicidal, then a
  one-on-one client-to-staff assignment would be necessary. Questioning the client until he responds
  would overwhelm him because he could not meet the nurse’s expectations to interact.
  CN: Psychosocial integrity; CL: Synthesize

Question 12

Q

The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse
attempts to engage the client in an interaction, but the client does not respond to the nurse. Which
response by the nurse is most appropriate?
“I’ll sit here with you for 15 minutes.”
“I’ll come back a little bit later to talk.”
“I’ll find someone else for you to talk with.”
“I’ll get you something to read.”

Answer

A

1. The most appropriate action is for the nurse to remain with the client even if the client does
  not engage in conversation with the nurse. A client with severe depression may be unable to engage in
  an interaction with the nurse because the client feels worthless and lacks the necessary energy to do
  so. However, the nurse’s presence conveys acceptance and caring, thus helping to increase the client’s
  self-worth. Telling the client that the nurse will come back later, stating that the nurse will find
  someone else for the client to talk with, or telling the client that the nurse will get her something to
  read conveys to the client that she is not important, reinforcing the client’s negative view of herself.
  Additionally, such statements interfere with the client’s development of a sense of security and trust in
  the nurse.
  CN: Psychosocial integrity; CL: Synthesize

Question 13

Q

After a few minutes of conversation, a female client who is depressed wearily asks the nurse,
“Why pick me to talk to? Go talk to someone else.” Which of the following replies by the nurse is
best?
“I’m assigned to care for you today, if you’ll let me.”
“You have a lot of potential, and I’d like to help you.”
“I’ll talk to someone else later.”
“I’m interested in you and want to help you.”

Answer

A

1. The nurse tells the client that the nurse is interested in her to increase the client’s sense of
  importance, worth, and self-esteem. Also, stating that the nurse wants to help conveys to the client that
  she is worthwhile and important. Telling the client that the nurse is assigned to care for her is
  impersonal and implies that the client is being uncooperative. Telling the client that the nurse is there
  because the client has potential for improvement will not help the client with low self-esteem because
  most people develop a sense of self-worth through accomplishment. Simply saying that the client has
  a lot of potential will not convince her that she is worthwhile. Telling the client that the nurse will
  talk to someone else later is not client focused and does not address the client’s question or concern.
  CN: Psychosocial integrity; CL: Synthesize

Question 14

Q

A client is receiving paroxetine (Paxil) 20 mg every morning. After taking the first three
doses, the client tells the nurse that the medication upsets the stomach. Which of the following
instructions should the nurse give to the client?
“Take the medication an hour before breakfast.”
“Take the medication with some food.”
“Take the medication at bedtime.”
“Take the medication with 4 oz (120 mL) of orange juice.”

Answer

A

1. Nausea and gastrointestinal upset is a common, but usually temporary, side effect of
  paroxetine (Paxil). Therefore, the nurse would instruct the client to take the medication with food to
  minimize nausea and stomach upset. Other more common side effects are dry mouth, constipation,
  headache, dizziness, sweating, loss of appetite, ejaculatory problems in men, and decreased orgasms
  in women. Taking the medication an hour before breakfast would most likely lead to further
  gastrointestinal upset. Taking the medication at bedtime is not recommended because Paxil can cause
  nervousness and interfere with sleep. Because orange juice is acidic, taking the medication with it,
  especially on an empty stomach, may lead to nausea or increase the client’s gastrointestinal upset.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 15

Q

The primary health care provider prescribes fluoxetine (Prozac) orally every morning for a
72-year-old client with depression. Which transient adverse effect of this drug requires immediate
action by the nurse?
Nausea.
Dizziness.
Sedation.
Dry mouth.

Answer

A

1. The presence of dizziness could indicate orthostatic hypotension, which may cause injury to
  the client from falling. Nausea, sedation, and dry mouth do not require immediate intervention by the
  nurse.CN: Pharmacological and parenteral therapies; CL: Analyze

Question 16

Q

Which of the following statements by a client taking trazodone (Desyrel) as prescribed by the
primary health care provider indicates to the nurse that further teaching about the medication is
needed?
“I will continue to take my medication after a light snack.”2. “Taking Desyrel at night will help me to sleep.”
“My depression will be gone in about 5 to 7 days.”
“I won’t drink alcohol while taking Desyrel.”

Answer

A

1. Symptom relief can occur during the first week of therapy, with optimal effects possible
  within 2 weeks. For some clients, 2 to 4 weeks is needed for optimal effects. The client’s statement
  that the depression will be gone in 5 to 7 days indicates to the nurse that clarification and further
  teaching is needed. Trazodone should be taken after a meal or light snack to enhance its absorption.
  Trazodone can cause drowsiness, and therefore the major portion of the drug should be taken at
  bedtime. The depressant effects of central nervous system depressants and alcohol may be potentiated
  by this drug.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 17

Q

A 62-year-old female client with severe depression and psychotic symptoms is scheduled for
electroconvulsive therapy (ECT) tomorrow morning. The client’s daughter asks the nurse, “How
painful will the treatment be for Mom?” The nurse should respond by saying which of the following?
“Your mother will be given something for pain before the treatment.”
“The primary health care provider will make sure your mother doesn’t suffer needlessly.”
“Your mother will be asleep during the treatment and will not be in pain.”
“Your mother will be able talk to us and tell us if she’s in pain.

Answer

A

1. The nurse should explain that ECT is a safe treatment and that the client is given an
  ultrashort-acting anesthetic to induce sleep before ECT and a muscle relaxant to prevent
  musculoskeletal complications during the convulsion, which typically lasts 30 to 60 seconds to be
  therapeutic. Atropine is given before ECT to inhibit salivation and respiratory tract secretions and
  thereby minimize the risk of aspiration. Medication for pain is not necessary and is not given before
  or during the treatment. Some clients experience a headache after the treatment and may request and
  be given an analgesic such as acetaminophen (Tylenol). Telling the daughter that the primary health
  care provider will ensure that the client does not suffer needlessly would not provide accurate
  information about ECT. This statement also implies that the client will have pain during the treatment,
  which is untrue.
  CN: Reduction of risk potential; CL: Synthesize

Question 18

Q

During a group session, a client who is depressed tells the group that he lost his job. Which
of the following responses by the nurse is best?
“It must have been very upsetting for you.”
“Would you tell us about your job?”
“You’ll find another job when you’re better.”
“You were probably too depressed to work.

Answer

A

1. By stating, “It must have been very upsetting for you,” the nurse conveys empathy to the
  client by recognizing the underlying meaning of a painful occurrence. The nurse’s statement invites the
  client to verbalize feelings and thoughts and lets the client know that the nurse is listening to and
  respects the client. Telling the client to talk about the job disregards the client’s feelings and is
  nontherapeutic for the depressed client because of underlying feelings of worthlessness and guilt that
  are commonly present. Telling the client that he will find another job when he is better or that he was
  probably too depressed to work is inappropriate because it disregards the client’s feelings and may
  promote additional feelings of failure and inadequacy in the client.
  CN: Psychosocial integrity; CL: Synthesize

Question 19

Q

A male client who is very depressed exhibits psychomotor retardation, a flat affect, and
apathy. The nurse observes the client to be in need of grooming and hygiene. Which of the following
nursing actions is most appropriate?
Explaining the importance of hygiene to the client.
Asking the client if he is ready to shower.
Waiting until the client’s family can participate in the client’s care.
Stating to the client that it’s time for him to take a shower.

Answer

A

1. The client with depression is preoccupied, has decreased energy, and cannot make
  decisions, even simple ones. Therefore, the nurse presents the situation, “It’s time for a shower,” and
  assists the client with personal hygiene to preserve his dignity and self-esteem. Explaining the
  importance of good hygiene to the client is inappropriate because the client may know the benefits of
  hygiene but is too fatigued and preoccupied to pay attention to self-care. Asking the client if he is
  ready for a shower is not helpful because the client with depression commonly cannot make even
  simple decisions. This action also reinforces the client’s feeling about not caring about showering.
  Waiting for the family to visit to help with the client’s hygiene is inappropriate and irresponsible on
  the part of the nurse. The nurse is responsible for making basic decisions for the client until the client
  can make decisions for himself.
  CN: Psychosocial integrity; CL: Synthesize

Question 20

Q

When developing the teaching plan for the family of a client with severe depression who is to
receive electroconvulsive therapy (ECT), which of the following information should the nurse
include?
Some temporary confusion and disorientation immediately after a treatment is common.
During an ECT treatment session, the client is at risk for aspiration.
Clients with severe depression usually do not respond to ECT.
The client will not be able to breathe independently during a treatment.

Answer

A

1. The family needs to be informed that some confusion and disorientation will occur as the
  client emerges from anesthesia immediately after ECT, to lessen their fear and anxiety about theprocedure. The nurse will assist the client with reorientation (time, person, and place) and will give
  clear, simple instructions. The client may need to lie down after ECT because of the effects of the
  anesthesia. Informing the family that there is a danger of aspiration during ECT is inappropriate and
  unnecessary. The risk of aspiration occurring during ECT is minimal because food and fluids are
  withheld for 6 to 8 hours before the treatment. In addition, the client receives atropine to inhibit
  salivation and respiratory tract secretions. Telling the family that the client will not be able to breathe
  independently during ECT may frighten them unnecessarily. If asked, the nurse should inform the
  family that the anesthesiologist mechanically ventilates the client with 100% oxygen immediately
  before the treatment. The client with severe depression responds to ECT. Usually, ECT is used for
  those who are severely depressed and not responding to pharmacotherapy and for those who are
  highly suicidal.
  CN: Psychosocial integrity; CL: Create

Question 21

Q

Which of the following comments indicates that a client understands the nurse’s teaching
about sertraline (Zoloft)?
“Zoloft will probably cause me to gain weight.”
“This medicine can cause delayed ejaculations.”
“Dry mouth is a permanent side effect of Zoloft.”
“I can take my medicine with St. John’s wort.”

Answer

A

1. Sertraline, like other selective serotonin reuptake inhibitors (SSRIs), can cause decreased
  libido and sexual dysfunction such as delayed ejaculation in men and an inability to achieve orgasm
  in women. SSRIs do not typically cause weight gain but may cause loss of appetite and weight loss.
  Dry mouth is a possible side effect, but it is temporary. The client should be told to take sips of water,
  suck on ice chips, or use sugarless gum or candy. St. John’s wort should not be taken with SSRIs
  because a severe reaction could occur.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 22

Q

The client with recurring depression will be discharged from the psychiatric unit. Which
suggestion to the family is best to help them prepare for the client’s return home?
Discourage visitors while the client is at home.
Provide for a schedule of activities outside the home.
Involve the client in usual at-home activities.
Encourage the client to sleep as much as possible.

Answer

A

1. It is best to involve the client in usual at-home activities as much as the client can tolerate
  them. Discouraging visitors may not be in the client’s best interest because visits with supportive
  significant others will help reinforce supportive relationships, which are important to the client’s self-
  worth and self-esteem. Providing for a schedule of activities outside the home may be overwhelming
  for the client initially. Involving the client in planning for outside activities would be appropriate.
  Encouraging the client to sleep as much as possible is nontherapeutic and promotes withdrawal from
  others.
  CN: Psychosocial integrity; CL: Synthesize

Question 23

Q

A client with major depression is to be discharged home tomorrow. When preparing the
client’s discharge plan, which of the following areas is most important for the nurse to review with
the client?
Future plans for going back to work.
A conflict encountered with another client.
Results of psychological testing.
Medication management with outpatient follow-up.

Answer

A

1. Medication management with outpatient follow-up is of vital importance to discuss with the
  client before discharge. The nurse teaches and clarifies any questions related to medication and
  outpatient treatment. The client also has the opportunity to voice feelings related to medication and
  treatment. The goal is to assist the client in making a successful transition from hospital to home with
  optimal functioning outside the hospital for as long as possible. The nurse may also need to assist
  with decreasing any anxiety the client may have related to discharge. Discussing future plans for
  returning to work or employment is not as immediate a concern as assisting with medication and
  treatment compliance. Noncompliance with medication is a primary cause of relapse in a client with
  a psychiatric disorder. Reviewing a conflict the client had encountered with another client is not
  appropriate or therapeutic at this time unless the client brings it to the nurse’s attention. The conflict
  should have been dealt with and resolved when it occurred. Reviewing the results of psychological
  testing is the responsibility of the primary health care provider if he chooses.
  CN: Psychosocial integrity; CL: Create

Question 24

Q

A client with major depression and psychotic features is admitted involuntarily to the
hospital. He will not eat because his “bowels have turned to jelly,” which the client states is
punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request
because commitment papers have been initiated by the primary health care provider. Which of the
following should the nurse identify as a criterion for the client to be legally committable?
Evidence of psychosis.
Being gravely disabled.
Risk of harm to self or others.
Diagnosis of mental illness.

Answer

A

1. Criteria for commitment include being gravely disabled and posing a harm to self or others.
  This client is not threatening to harm himself in the form of suicide or to harm others. The client isgravely disabled because of his inability to care for himself—namely, not eating because of his
  delusion. Evidence of psychosis or psychotic symptoms or diagnosis of a mental illness alone does
  not make the client legally eligible for commitment.
  CN: Management of care; CL: Apply

Question 25

Q

The client who has been taking venlafaxine (Effexor) 25 mg PO three times a day for the past
2 days states, “This medicine isn’t doing me any good. I’m still so depressed.” Which of the following
responses by the nurse is most appropriate?
“Perhaps we’ll need to increase your dose.”
“Let’s wait a few days and see how you feel.”
“It takes about 2 to 4 weeks to receive the full effects.”
“It’s too soon to tell if your medication will help you.”

Answer

A

1. The client needs to be informed of the time lag involved with antidepressant therapy.
  Although improvement in the client’s symptoms will occur gradually over the course of 1 to 2 weeks,
  typically it takes 2 to 4 weeks to get the full effects of the medication. This information will help the
  client be compliant with medication and will also help in decreasing any anxiety the client has about
  not feeling better. The client’s dose may not need to be increased; it is too early to determine the full
  effectiveness of the drug. Additionally, such a statement may increase the client’s anxiety and diminish
  self-worth. Telling the client to wait a few days discounts the client’s feelings and is inappropriate.
  Although it is too soon to tell whether the medication will be effective, telling this to the client may
  cause the client undue distress. This statement is somewhat negative because it is possible that the
  medication will not be effective, possibly further compounding the client’s anxiety about not feeling
  better.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 26

Q

The client states to the nurse, “I take citalopram (Celexa) 40 mg every day as my primary
health care provider prescribed. I have also been taking St. John’s wort 750 mg daily for the past 2
weeks.” Which of the following indicate that the client is developing serotonin syndrome? Select all
that apply.
Confusion.
Restlessness.
Constipation.
Diaphoresis.
Ataxia.

Answer

A

1, 2, 4, 5. Serotonin syndrome can occur if a selective serotonin reuptake inhibitor is
combined with a monoamine oxidase inhibitor, a tryptophan-serotonin precursor, or St. John’s wort.
Signs and symptoms of serotonin syndrome include mental status changes, such as confusion,
restlessness or agitation, headache, diaphoresis, ataxia, myoclonus, shivering, tremor, diarrhea,
nausea, abdominal cramps, and hyperreflexia. Constipation is not associated with serotonin
syndrome.
CN: Pharmacological and parenteral therapies; CL: Analyze

Question 27

Q

When teaching the client with atypical depression about foods to avoid while taking
phenelzine (Nardil), which of the following should the nurse include?
Roasted chicken.
Salami.
Fresh fish.
Hamburger.

Answer

A

1. Phenelzine is a monoamine oxidase inhibitor (MAOI). MAOIs block the enzyme
  monoamine oxidase, which is involved in the decomposition and inactivation of norepinephrine,
  serotonin, dopamine, and tyramine (a precursor to the previously stated neurotransmitters). Foods
  high in tyramine—those that are fermented, pickled, aged, or smoked—must be avoided because,
  when they are ingested in combination with MAOIs, a hypertensive crisis occurs. Some examples
  include salami, bologna, dried fish, sour cream, yogurt, aged cheese, bananas, pickled herring,
  caffeinated beverages, chocolate, licorice, beer, red wine, and alcohol-free beer.
  CN: Pharmacological and parenteral therapies; CL: Apply

Question 28

Q

A client is taking phenelzine (Nardil) 15 mg PO three times a day. The nurse is about to
administer the 1 PM dose when the client tells the nurse about having a throbbing headache. Which of
the following should the nurse do first?
Give the client an analgesic prescribed PRN.2. Call the primary health care provider to report the symptom.
Administer the client’s next dose of phenelzine.
Obtain the client’s vital signs.

Answer

A

1. The nurse should first take the client’s vital signs because the client could be experiencing a
  hypertensive crisis, which requires prompt intervention. Signs and symptoms of a hypertensive crisis
  include occipital headache, a stiff or sore neck, nausea, vomiting, sweating, dilated pupils and
  photophobia, nosebleed, tachycardia, bradycardia, and constricting chest pain. Giving this client an
  analgesic without taking his vital signs first is inappropriate. After the client’s vital signs have been
  obtained, then the nurse would call the primary health care provider to report the client’s problems
  and vital signs. Administering the client’s next dose of phenelzine before taking his vital signs could
  result in a dangerous situation if the client is experiencing a hypertensive crisis.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 29

Q

A female client with severe depression and weight loss has not eaten since admission to the
hospital 2 days ago. Which of the following approaches should the nurse include when developing
this client’s plan of care to ensure that she eats?
Serving the client her meal trays in her room.
Sitting with the client and spoon-feeding if required.
Calling the family to bring the client food from home.
Explaining the importance of nutrition in recovery.

Answer

A

1. A depressed client commonly is not interested in eating because of the psychopathology of
  the disorder. Therefore, the nurse must take responsibility to ensure that the client eats, includingspoon-feeding the client (placing the food on the spoon, putting the food near the client’s mouth, and
  asking her to eat) if necessary. Serving the client her tray in her room does not ensure that she will
  eat. Calling the family to bring the client food from home usually is allowed, but it is still the nurse’s
  responsibility to ensure that the client eats. Explaining the importance of nutrition in recovery is not
  helpful. The client may intellectually know that eating is important but may not be interested in eating
  or want to eat.
  CN: Psychosocial integrity; CL: Synthesize

Question 30

Q

After administering a prescribed medication to a client who becomes restless at night and has
difficulty falling asleep, which of the following nursing actions is most appropriate?
Sitting quietly with the client at the bedside until the medication takes effect.
Engaging the client in interaction until the client falls asleep.
Reading to the client with the lights turned down low.
Encouraging the client to watch television until the client feels sleepy.

Answer

A

1. To promote adequate rest (6 to 8 hours per night) and to eliminate hyposomnia, the nurse
  should sit with the client at the bedside until the medication takes effect. The presence of a caring
  nurse provides the client with comfort and security and helps to decrease the client’s anxiety.
  Engaging the client in interaction until the client falls asleep, reading to the client, or encouraging the
  client to watch television may be too stimulating for the client, consequently increasing rather than
  decreasing the client’s restlessness.
  CN: Psychosocial integrity; CL: Synthesize

Question 31

Q

Which of the following behaviors exhibited by a client with depression should lead the nurse
to determine that the client is ready for discharge?
Interactions with staff and peers.
Sleeping for 4 hours in the afternoon and 4 hours at night.
Verbalization of feeling in control of self and situations.
Statements of dissatisfaction over not being able to perform at work.

Answer

A

1. The client who verbalizes feeling in control of self and situations no longer feels powerless
  to affect an outcome but realizes that one’s actions can have an impact on self and situations. It is
  common for the client with depression to feel powerless to affect an outcome and to feel a lack of
  control over a situation. Although interacting with staff and peers is a positive action, the client could
  be conversing in a negative or nontherapeutic manner. Sleeping 4 hours in the afternoon and 4 hours at
  night is evidence of symptomatology and does not indicate improvement or recovery. Verbalizing
  dissatisfaction over not being able to perform at work indicates that the client is most likely focusing
  on shortcomings and powerlessness.
  CN: Psychosocial integrity; CL: Analyze

Question 32

Q

The client with major depression and suicidal ideation has been taking bupropion
(Wellbutrin) 100 mg PO four times daily for 5 days. Assessment reveals the client to be somewhat
less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of
each meal. At this time, the nurse should monitor the client specifically for which of the following
behaviors?
Seizure activity.
Suicide attempt.
Visual disturbances.
Increased libido.

Answer

A

1. The nurse must monitor the client for a suicide attempt at this time when the client is
  starting to feel better because the depressed client may now have enough energy to carry out an
  attempt. Bupropion inhibits dopamine reuptake; it is an activating antidepressant and could cause
  agitation. Although bupropion lowers the seizure threshold, especially at doses greater than 450
  mg/day, and visual disturbances and increased libido are possible adverse effects, the nurse must
  closely monitor the client for a suicide attempt. As the client with major depression begins to feel
  better, the client may have enough energy to carry out an attempt.
  CN: Psychosocial integrity; CL: Analyze

Question 33

Q

Which of the following outcomes should the nurse include in the initial plan of care for a
client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and
unresponsiveness to the nurse’s questions?
The client will initiate interactions with peers.
The client will participate in milieu activities.
The client will discuss adaptive coping techniques.
The client will interact with the nurse.

Answer

A

1. In the initial plan of care, the most appropriate outcome would be that the client will
  interact with the nurse. First, the client would begin interacting with one individual, the nurse. The
  nurse would gradually assist the client to engage in interactions with other clients in one-on-one
  contacts, progressing toward informal group gatherings and eventually taking part in structured group
  activities. The client needs to experience success according to the client’s level of tolerance.
  Initiating interactions with peers occurs when the client can gain a measure of confidence and self-
  esteem instead of feeling intimidated or unduly anxious. Discussing adaptive coping techniques is an
  outcome the client may be able to reach when symptoms are not as severe and the client can
  concentrate on improving coping skills.
  CN: Psychosocial integrity; CL: Synthesize

Question 34

Q

When preparing a teaching plan for a client about imipramine (Tofranil), which of the
following substances should the nurse tell the client to avoid while taking the medication?
Caffeinated coffee.
Sunscreen.
Alcohol.
Artificial tears.

Answer

A

1. Imipramine, a tricyclic antidepressant, in combination with alcohol will produce additivecentral nervous system depression. Although caffeinated coffee is safe to use when the client is taking
  imipramine, it is not recommended for a client with depression who may be experiencing sleep
  disturbances. Imipramine may cause photosensitivity so the client would be instructed to use
  sunscreen and protective clothing when exposed to the sun. Reduced lacrimation may occur as a side
  effect of imipramine. Therefore, the use of artificial tears may be recommended.
  CN: Pharmacological and parenteral therapies; CL: Create

Question 35

Q

The client with depression who is taking imipramine (Tofranil) states to the nurse, “My
doctor wants me to have an electrocardiogram (ECG) in 2 weeks, but my heart is fine.” Which
response by the nurse is most appropriate?
“It’s routine practice to have ECGs periodically because there is a slight chance that the drug may
affect the heart.”
“It’s probably a precautionary measure because I’m not aware that you have a cardiac
condition.”
“Try not to worry too much about this. Your doctor is just being very thorough in monitoring
your condition.”
“You had an ECG before you were prescribed imipramine and the procedure will be the
same.”

Answer

A

1. Telling the client that ECGs are done routinely for all clients taking imipramine, a tricyclic
  antidepressant, is an honest and direct response. Additionally, it provides some reassurance for the
  client. Commonly, a client with depression will ruminate, leading to needless increased anxiety.
  Tricyclic antidepressants may cause tachycardia, ECG changes, and cardiotoxicity. Telling the client
  that it’s probably a precautionary measure because the nurse is not aware of a cardiac condition
  instills doubt and may cause undue anxiety for the client. Telling the client not to worry because the
  doctor is very thorough dismisses the client’s concern and does not give the client adequate
  information. Explaining that the client had an ECG before initiating therapy with imipramine and that
  the procedure will be the same does not answer the client’s question.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 36

Q

When assessing a client who is receiving tricyclic antidepressant therapy, which of the
following should alert the nurse to the possibility that the client is experiencing anticholinergic
effects?
Tremors and cardiac arrhythmias.
Sedation and delirium.
Respiratory depression and convulsions.
Urine retention and blurred vision.

Answer

A

1. Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral)
  nervous system, include urine retention, blurred vision, dry mouth, and constipation. Tremors, cardiac
  arrhythmias, and sexual dysfunction are possible side effects, but they are caused by increased
  norepinephrine availability. Sedation and delirium are not anticholinergic effects. Sedation may be a
  therapeutic effect because many clients with depression experience agitation and insomnia. Delirium,
  typically not a side effect, would indicate toxicity, especially in elderly clients. Respiratory
  depression, convulsions, ataxia, agitation, stupor, and coma indicate tricyclic antidepressant toxicity.
  CN: Pharmacological and parenteral therapies; CL: Analyze

Question 37

Q

A client with depression who is taking doxepin (Sinequan) 100 mg PO at bedtime has
dizziness on arising. Which of the following suggestions is most appropriate?
“Try taking a hot shower.”
“Get up slowly and dangle your feet before standing.”
“Stay in bed until you are feeling better.”
“You need to limit the fluids you drink.”

Answer

A

1. Doxepin and other tricyclic antidepressants may cause postural hypotension, especially in
  the morning. Postural hypotension occurs because the tricyclic antidepressant inhibits the body’s
  natural vasoconstrictive reaction when a person stands. The nurse regularly monitors the client’s vital
  signs, both lying and standing. The nurse should instruct the client to rise slowly and dangle his feet
  before standing. Advising the client to take a hot shower is detrimental to the client’s safety. Heat
  causes vasodilation, which could further exacerbate the dizziness, placing the client at risk for falls
  and subsequent injury. Telling the client to stay in bed until he is feeling better is not helpful and is
  impractical. The client with depression would rather stay in bed and withdraw from others. Placing
  the client on fluid restriction is detrimental to the client with depression whose fluid and food intake
  may be inadequate.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 38

Q

The primary health care provider prescribes mirtazapine (Remeron) 30 mg PO at bedtime for
a client diagnosed with depression. The nurse should:
Give the medication as prescribed.
Question the primary health care provider’s prescription.
Request to give the medication in the morning.
Give the medication in three divided doses.

Answer

A

1. The nurse should give the medication as prescribed. Mirtazapine is given once daily,
  preferably at bedtime to minimize the risk of injury resulting from postural hypotension and sedative
  effects. The usual dosage ranges from 15 to 45 mg. There is no reason to question the primary health
  care provider’s prescriptions. The nurse should administer the medication as prescribed. Requesting
  to give the medication in three divided doses is inappropriate and demonstrates the nurse’s lack of
  knowledge about the drug.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 39

Q

A client taking mirtazapine is disheartened about a 20 lb (9 kg) weight gain over the past 3
months. The client tells the nurse, “I stopped taking my mirtazapine 15 days ago. I don’t want to get
depressed again, but I feel awful about my weight.” Which response by the nurse is most appropriate?
“Focusing on diet and exercise alone should control your weight.”
“Your depression is much better now, so your medication is helping you.”
“Look at all the positive things that have happened to you since you started mirtazapine.”
“I hear how difficult this is for you and will help you approach the doctor about it.”

Answer

A

1. The nurse should express concern for the client and offer to help the client speak with the
  primary health care provider, which will lend support to the client’s concerns. The client who has
  stopped the medication must be taken seriously because medication noncompliance could result in a
  recurrence of symptoms of depression. Telling the client to focus on diet and exercise ignores the
  client’s feelings and subtly implies the weight gain is the client’s fault. Pointing out that the medication
  has helped and that positive things have happened since the depression lifted may be true, but it does
  not address the client’s current feelings or needs.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 40

Q

When developing a teaching plan for a client about the medications prescribed for
depression, which of the following components is most important for the nurse to include?
Pharmacokinetics of the medication.2. Current research related to the medication.
Management of common adverse effects.
Dosage regulation and adjustment.

Answer

A

1. Compliance with medication therapy is crucial for the client with depression. Medication
  noncompliance is the primary cause of relapse among psychiatric clients. Therefore, the nurse needs
  to teach the client about managing common adverse effects to promote compliance with medication.
  Teaching the client about the medication’s pharmacokinetics may help the client to understand the
  reason for the drug. However, teaching about how to manage common adverse effects to promote
  compliance is crucial. Current research about the medication is more important to the nurse than to the
  client. Teaching about dosage regulation and adjustment of medication may be helpful, but typically
  the primary health care provider, not the client, is the person in charge of this aspect.
  CN: Pharmacological and parenteral therapies; CL: Create

Question 41

Q

The client diagnosed with severe major depression has been taking escitalopram 10 mg daily
for the past 2 weeks. Which of the following parameters should the nurse monitor most closely at this
time?
Suicidal ideation.
Sleep.
Appetite.
Energy level.

Answer

A

1. After about 2 weeks of medication therapy, the nurse should expect improvements in sleep,
  appetite, and energy though mood may not have improved significantly yet. The increased energy
  related to better sleep and food intake gives the client the ability to act on thoughts to harm self
  (suicide) since the depressed mood has not completely lifted.
  CN: Pharmacological and parenteral therapies; CL: Analyze

Question 42

Q

A client taking paroxetine (Paxil) 40 mg PO every morning tells the nurse that her mouth
“feels like cotton.” Which of the following statements by the client necessitates further assessment by
the nurse?
“I’m sucking on ice chips.”
“I’m using sugarless gum.”
“I’m sucking on sugarless candy.”
“I’m drinking 12 glasses of water every day.”

Answer

A

1. Dry mouth is a common, temporary side effect of paroxetine. The nurse needs to further
  assess the client’s water intake when the client states she is drinking lots of water. Excessive intake of
  water could be harmful to the client and could lead to electrolyte imbalance. Dry mouth is caused by
  the medication, and drinking a lot of water will not eliminate it. Sucking on ice chips or using
  sugarless gum or candy is appropriate to ease the discomfort of dry mouth associated with paroxetine.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 43

Q

The client with depression has been consistent with taking 12.5 mg of paroxetine (Paxil)
extended release daily. The nurse judges the client to be benefiting from this drug therapy when the
client demonstrates which of the following behaviors? Select all that apply.
Takes 2-hour evening naps daily.
Completes homework assignments.
Decreases pacing.
Increases somatization.
Verbalizes feelings.

Answer

A

2, 3, 5. Symptoms of depression include depressed mood, anhedonia, appetite disturbance,
sleep disturbance, psychomotor disturbance, fatigue, feelings of worthlessness, excessive or
inappropriate guilt, decreased concentration, and recurrent thoughts of death or suicide. Paroxetine is
a selective serotonin reuptake inhibitor antidepressant that also can be used to treat anxiety. Improved
concentration, verbalization of feelings, and decreased agitation or pacing are signs of improvement.
Taking 2-hour evening naps daily is still a sign of fatigue or lack of energy, and the increased use of
somatization (bodily problems) could be signs of continued symptoms of depression.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 44

Q

A client diagnosed with major depression has sleep and appetite disturbances and a flat
affect and is withdrawn. The client has been taking fluvoxamine (Luvox) 50 mg twice daily for 5
days. Which client behavior is most important to report to the next shift?
Client’s flat affect.
Client’s interacting with a visitor.
Client sleeping from 11 PM to 6 AM .
Client spending the entire evening in her room.

Answer

A

1. The most important behavior to report to the next shift is that the client was able to sleep
  from 11 PM to 6 AM . This indicates that improvement in the symptoms of depression is occurring as a
  result of pharmacologic therapy. The nurse would expect to observe improvement in sleep, appetite,
  and psychomotor behavior first before improvement in cognitive symptoms. The client’s flat affect is
  still a symptom of depression. The fact that the client had a visitor is not as important as changes in
  the client’s behavior. Spending the evening in her room is a continuation of the client’s withdrawnbehavior and is important to report but not as important as the improvement in sleep.
  CN: Psychosocial integrity; CL: Analyze

Question 45

Q

A client with major depressive disorder has independently showered, dressed, and washed
her hair for the first time since her admission to the inpatient unit 4 days ago. In an interaction with the
nurse, she still stresses her faults. She states “I’m just no good; I can’t do anything right.” The nurse’s
best response would be:
“You look very nice today.”
“You were able to shower, wash your hair, and dress today.”
“I’ll get out the craft project that you wanted to complete.”
“What is your goal for today?”

Answer

A

1. An objective reflection by the nurse based on actual behavior is the best affirmation for the
  client to help boast self-esteem. Depressed persons tend to reject positive opinions from others.
  Picking a project for such a client is also likely to bring a negative response and/or foster
  dependence. Antipsychotics are sometimes prescribed for clients with bipolar disorder and would
  not pose a special concern.
  CN: Psychosocial integrity; CL: Apply

Question 46

Q

A nurse is educating a client who has been diagnosed with dysthymia about possible
treatment for the disorder. Which response by the nurse is most appropriate?1. “Antidepressants, particularly the selective serotonin reuptake inhibitor (SSRI) group, offer
you the best treatment for your dysthymia.”
“Doctors recommend that clients experiencing dysthymia receive electroconvulsive therapy
(ECT) to treat their disorder.”
“Because you have a mild, though long-lasting dysthymic mood, psychotherapy can usually bring
improvement with less likelihood of the need for medication.”
“Since your dysthymia indicates a long-lasting mild depression, long-term psychoanalysis
would be the best treatment for you.”

Answer

A

1. Dysthymia is a milder, persistent type of depression in which sufferers are able to
  minimally carry on their work. Antidepressant and ECT are treatments used for occurrences of major
  depression with ECT being used as a last resort when several medications fail. Psychoanalysis is a
  very involved, long-term treatment rarely used now due to its cost and the long period of treatment
  required for results.
  CN: Psychosocial integrity; CL: Synthesize

Question 47

Q

A client comes to the mental health clinic for a follow-up visit for a diagnosis of major
depressive disorder. He says that he has been taking his escitalopram oxalate as prescribed since his
second hospitalization 3 months ago. He tells the nurse that he is feeling “like my old self again.”
Now he wants to stop taking medication. “I don’t want to be dependent on meds like my father.” What
is the nurse’s best initial response to him?
“After another 3 months of stability, it might be safe for you to go off the escitalopram.”
“After two significant episodes, you will need to take an antidepressant indefinitely.”
“Research indicates that individuals who have had two major depressive episodes have a 70%
chance of having a third episode.”
“It is likely that you can learn to manage your depression with a regular exercise regime and a
healthy diet.”

Answer

A

1. After two episodes of a major depressive disorder, the likelihood of a third episode
  increases to 70%. This information would be useful to convey prior to discussing the importance of
  continuing his medication. This client also has a family history of depression. A healthy diet and
  exercise are very significant adjuncts to the therapeutic plan but may not be sufficient as stand-alone
  therapy.
  CN: Physiological integrity; CL: Analyze

Question 48

Q

The intake nurse is making an assessment of a client who has just arrived at the emergency
department. Which of the following comments from this client who is taking Nardil (phenelzine), a
monoamine oxidase (MAO) inhibitor, for treatment-resistant depression should be given top priority?
“My bowels haven’t moved in the last 2 days.”
“What was my temperature? I’m feeling warm.”
“My legs feel stiff after I sit in the chair for a while.”
“I have a throbbing headache.”

Answer

A

1. A serious, life-threatening reaction to MAO inhibitors is hypertensive crisis. Although this
  medication is inclined to reduce blood pressure, in combination with too much tyramine (present in
  other drugs and foods), blood pressure can rise to a dangerous level. A throbbing headache could be
  a significant indicator of an impending crisis.
  CN: Pharmacological and parenteral therapies; CL: Analyze

Question 49

Q

Which of the following statements made by an adolescent who has just begun taking an
antidepressant would indicate the need for further teaching about the action of antidepressants in
treating depression?
“Now that I have been taking my antidepressant for a week, I’m going to feel better about myself.”
“A week ago when I started my antidepressant, I didn’t care about eating, but now I want to eat
a bit more.”
After a week of taking my antidepressant, I can sleep a little better—6 hours or so each night.”
“Now that I’ve had a week of my antidepressant, it is a little easier to get up in the morning.”

Answer

A

1. In the first week or so of taking an antidepressant, the vegetative symptoms of depression
  (poor sleep, appetite, and energy level) improve. However, it takes 3 to 4 weeks for improvement in
  self-concept/self-esteem to take place.
  CN: Pharmacological therapies and IVs; CL: Evaluate

Question 50

Q

The Client with Bipolar Disorder, Manic Phase
50. A client comes to the mental health clinic saying that he feels so down and lacking in energy
with “loss of interest in everything.” He tells the nurse that he received some samples of a new
medication from his primary care physician last week to relieve his depression. The nurse recalls that
this client has a history of bipolar I disorder with hospitalization for a significant manic episode.
With this knowledge, the nurse would have special concern if he is taking which of the following
categories of medication?
1. Atypical antipsychotics.
2. Mood stabilizers/antimanics.
3. Antianxiety agents (benzodiazepines).
4. Selective serotonin reuptake inhibitor (SSRI) antidepressant.

Answer

A

The Client with Bipolar Disorder, Manic Phase
50. 4. The most urgent consideration for intervention and for teaching is the fact that for
individuals with a history of bipolar disorder, antidepressants when taken alone can push the person
into mania. Antipsychotics are sometimes prescribed for clients with bipolar disorder and would not
pose a special concern. Individuals with bipolar disorder are typically treated with mood stabilizers,
and benzodiazepines are sometimes used in the short term to give a client relief before the mood
stabilizers can take effect.
CN: Pharmacological and parenteral therapies; CL: Analyze

Question 51

Q

In a predischarge program to educate clients with bipolar disorder and their family members,
the nurse emphasizes that the most significant indicators for the onset of relapse include which of the
following symptoms?
A sense of pleasure and motivation for new endeavors.
Decreased need for sleep and racing thoughts.
Self-concern about increase in energy.
Leaving a good job to start a new business.

Answer

A

1. Decreased need for sleep and racing thoughts are the most prominent hallmarks of mania.
  Feelings of pleasure, motivation, and increased energy, within reason, are desired experiences. Alsoleaving a job to start a new business is not, in itself, a sign of impending illness.
  CN: Psychosocial integrity; CL: Apply

Question 52

Q

A client has just been admitted to the hospital for medication adjustment after outpatient
treatment failure of his bipolar disorder and returning mania. He tells his primary nurse about his
medications and treatment. Which of his following statements would raise the most urgent need for
more medication instruction about his lithium therapy?
“My doctor tells me that my lithium level is 1.0 so I don’t have to worry about my levels.”
“I’ve been getting a lot of good exercise playing on a local soccer team.”
“I’m trying hard to watch my diet and eat healthy.”
“I have learned to take my lithium even when I’m not feeling well, like when I had the stomach flu.”

Answer

A

1. The therapeutic serum level for lithium is 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Levels due
  fluctuate with fluid intake and output, however. Therefore, the most urgent matter for teaching is the
  client’s comment about taking his lithium during excessive loss of fluids during an episode of
  “stomach flu” with diarrhea. Exercising is only concerning if the client becomes dehydrated. A
  healthy diet is indicated while taking lithium.
  CN: Pharmacological and parenteral therapies; CL: Analyze

Question 53

Q

A young woman comes to the mental health clinic for her routine medication follow-up. She
has been married for 2 years and reports that she and her husband are ready to start a family. She has
a diagnosis of bipolar I disorder and has been well managed on divalproex sodium (Depakote) for at
least 3 years. What is the most essential counsel for the nurse to give her?
“Schedule an appointment for a complete gynecological exam if you have not had one in the
past year.”
“Pay careful attention to eating healthy from this point on in order to maximize the health of
both mother and baby.”
“Check with your prescriber today as Depakote carries an increased risk for birth defects, especially
during the first 3 months of pregnancy.”
“It is very important for you to take steps to reduce your stress and this will help you to stay in
balance during your pregnancy and reduce your chances of developing post-partum
depression.”

Answer

A

1. All of these options need to be addressed. However, it is vital that this young woman
  receive counseling about the serious birth defects that have an increased incidence with the taking of
  Depakote during the first trimester of pregnancy. These problems include craniofacial abnormalities
  (cleft palate), organ malformations (holes in the heart and urinary tract problems), limb deficiencies,
  and developmental delays. The chances of preeclampsia and premature labor are also increased.
  CN: Reduction of risk potential; CL: Analyze

Question 54

Q

A health care provider has prescribed valproic acid for a client with bipolar disorder who
has achieved limited success with lithium carbonate. The nurse should instruct the client about whichof the following?
Follow-up blood tests are necessary while on this medication.
The extended-release tablet can be crushed if necessary for ease of swallowing.
Tachycardia and upset stomach are common side effects.
Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning

Answer

A

1. Valproic acid can cause hepatotoxicity, so regular liver function tests are needed. Other
  side effects include nausea and drowsiness. Extended-release tablets should not be split or crushed;
  doing so changes their absorption. Alcohol should never be mixed with this medication. There will
  be medication in the client’s body at all times.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 55

Q

A young adult client diagnosed with bipolar disorder has been managing the disorder
effectively with medication and treatment for several years. The client suddenly becomes manic. The
nurse reviews the client’s medication record. Which of the following medications may have
contributed to the development of his manic state?
MEDICATION RECORD
Amitriptyline 50 mg PO daily HS
‘Prednisone 20 mg PO daily
Buspirone HCl 5 mg PO three times a day
Gabapentin 300 mg PO three time a day
Amitriptyline.
Prednisone.
Buspirone.
Gabapentin.

Answer

A

1. The use of prednisone or other steroids can initiate a manic state in a bipolar client even if
  he is well controlled on medication. The other medications would decrease the client’s depression,
  mood swings, and anxiety, making him calmer rather than more agitated.
  CN: Pharmacological and parenteral therapies; CL: Analyze

Question 56

Q

The client with acute mania has been admitted to the inpatient unit voluntarily. The nurse
approaches the client with medication to be taken orally as prescribed by the primary health care
provider. The client states, “I don’t need that stuff.” Which response by the nurse is best?
“You can’t refuse to take this medication.”
“If you don’t take it orally, I’ll give you a shot.”
“The medication will help you feel calmer.”
“I’ll get you some written information about the medication.

Answer

A

1. The nurse should first attempt a collaborative approach to increasing adherence to the
  prescribed medication regimen. Giving written medication information to a client with acute mania is
  poor nursing judgment, because a client with acute mania cannot benefit from written information as a
  result of impaired ability to focus and concentrate.
  CN: Management of care; CL: Synthesize

Question 57

Q

A nurse observes a male client who is hyperactive and intrusive sitting very close to a female
client with his arm around her shoulders. The nurse hears the male client tell a sexually explicit joke.
The nurse approaches the client and asks him to walk down the hallway. Which of the following
statements by the nurse should benefit the client?
“She will not want to be around you with that kind of talk.”
“Telling sexual jokes and touching others is not permitted here.”
“You need to be careful about what you say to other people.”
“I think a time-out in your room would be appropriate now.”

Answer

A

1. The nurse clearly informs the client about behavior that is unacceptable on the unit, such as
  voicing jokes with sexual content and touching others. Setting limits on behavior provides safety and
  security to the client and conveys to the client that he is worthy of help. Saying “she will not want to
  be around you with that kind of talk” and “you need to be careful about what you say to others” does
  not clearly inform the client about behaviors that are unacceptable and implies that the client can
  control behaviors if he chooses. A time-out in the client’s room does not inform the client about the
  inappropriateness of his behaviors and could be interpreted by the client as punitive as well as
  diminishing his self-esteem.
  CN: Psychosocial integrity; CL: Synthesize

Question 58

Q

A client states to a nurse, “Hey sweetie, you’re looking good today.” Which of the following
responses by the nurse is best?
“Thank you for being so kind and thoughtful.”
“I know you are only teasing me.”
“My name is Molly, and I am a nurse on the unit today.”
“I am not here to receive compliments from clients.”

Answer

A

1. The nurse states her identity and purpose for being on the unit to clarify any misperception
  by the client. “Thank you for being so kind,” “I know you are only teasing me,” and “I am not here to
  receive compliments from clients” are nontherapeutic statements and do not clarify the nurse’s identityand purpose.
  CN: Psychosocial integrity; CL: Synthesize

Question 59

Q

A client with acute mania fails to respond to a nurse’s interventions to decrease his agitation.
The nurse has attempted to defuse the client’s anger, but the client refuses to participate in
interventions that would lower anxiety. Which action should the nurse take next?
Seclude the client.
Restrain the client.
Medicate the client.
Control the client.

Answer

A

1. The nurse should medicate the client who does not respond to verbal interventions and
  whose anxiety is escalating. This will reduce the client’s anxiety and agitation and prevent harm or
  injury to the client and others. Seclusion, restraint, and controlling the client are a last resort and
  require a primary health care provider’s prescription and close assessment for when the prescriptions
  can be discontinued.
  CN: Psychosocial integrity; CL: Synthesize

Question 60

Q

The client with mania is irritable and insulting to a nursing assistant. The nursing assistant
states, “I can’t believe Mark is so rude. Shouldn’t he be overly happy?” Which of the following
responses by the nurse should help the nursing assistant understand the client’s behavior?
“It’s our responsibility to listen to him even though we might not like what he’s saying.”
“We must reprimand Mark for doing that because there is no reason for him to behave like
that.”
“I will go and speak to him about his behavior and make sure he understands that he needs to
control what he is saying.”
“I know it’s difficult but Mark is a client whose irritable mood is a symptom of his mania.”

Answer

A

1. The nurse should help the nursing assistant understand the client’s behavior by stating that
  his irritable mood is a symptom of mania. Not all clients with mania are euphoric or have an
  expansive mood. Saying, “It’s our responsibility to listen to him even though we might not like what
  he’s saying” does not help the nursing assistant understand the client with mania. Reprimanding the
  client for his behavior and asking him to control his behavior are inappropriate actions and show
  poor nursing judgment and a lack of understanding of the manic client.
  CN: Psychosocial integrity; CL: Synthesize

Question 61

Q

61. Which milieu activity should the nurse recommend to a client with acute mania? Select all
that apply.
1. Scheduled rest periods.
2. Relaxation exercises.
3. Listening to soft music.
4. Watching television.
5. Aerobic exercises.

Answer

A

1, 2, 3, 5. Scheduled rest periods, relaxation exercises, and listening to soft music are
activities that reduce environmental stimuli for the client who is hyperactive, talkative, easily
distracted, irritable, and angry. Aerobic exercise is also beneficial to discharge some of the client’s
need to be active. Watching television is not therapeutic because it would stimulate the client with
acute mania.
CN: Psychosocial integrity; CL: Apply

Question 62

Q

A nurse is assessing a client experiencing hypomania who wants to stop her mood stabilizing
medication because she is “feeling good,” has a high energy level, and thinks she is productive at
work. Which response by the nurse is most appropriate?
“Maybe you really don’t need your medication anymore.”
“If you stop your medication, your behavior will quickly spiral out of control.”
“I believe you were hospitalized the last time you stopped your medication.”
“Why don’t you cut your medication dosage in half for a while and see how you respond?”

Answer

A

1. Reminding the client of past consequences of stopping the medication may help her realize
  the risks of stopping the medication again. Options 1 and 4 encourage the client’s misperception that
  she only needs medication when she feels depressed or manic rather than recognizing that her mood
  stabilizer can prevent her from experiencing those extreme highs and lows. Option 2 describes what
  will happen if she stops her medication, but if the client had recognized the consequences, she
  wouldn’t be contemplating stopping the medication.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 63

Q

The client with acute mania is prescribed 600 mg of lithium (lithium carbonate) PO three
times per day. The primary health care provider also prescribes 5 mg of haloperidol (Haldol) PO at
bedtime. Which action should the nurse take?
Administer the medication as prescribed.
Question the primary health care provider about the prescription.
Administer the Haldol, but not the lithium.
Consult with the nursing supervisor before administering the medications.

Answer

A

1. The nurse should administer the medication as prescribed. Lithium has a clinical response
  lag time of 1 to 2 weeks. Haloperidol is prescribed temporarily to produce a neuroleptic effect until
  the lithium starts to produce a clinical response. Haldol is usually discontinued when the lithium
  starts to take effect.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 64

Q

The client with an Axis I diagnosis of bipolar disorder, manic phase, states to the nurse, “I’m
the Queen of England. Bow before me.” The nurse interprets this statement as important to document
as which of the following areas of the mental status examination?
Psychomotor behavior.
Mood and affect.
Attitude toward the nurse.4. Thought content.

Answer

A

andiose delusion and refers to thought content of the mental status examination. Examples of
psychomotor behavior to be documented would include excited, typically exaggerated and repetitive
physical movements, and excessive talking and gesturing. Mood is a subjective state, and affect is an
observable expression of emotion. Mood is what a client tells you she is feeling, and affect is what
you see the client feeling. For example, the client may state that she feels sad or happy in reference to
mood. Affect refers to the display of physical emotion, commonly described as “appropriate” or
“flat.” Attitude toward the nurse refers to the client’s behavior in the presence of the nurse during themental status examination (pleasant and cooperative, irritable, and guarded).
CN: Psychosocial integrity; CL: Analyze

Answer 65

A

1. Decreasing external stimuli is the intervention most likely to decrease the emotional lability
  and minimize its effect on other clients. While the client is displaying emotional lability, this behavior
  has not reached the level where involuntary isolation (seclusion) or physical restraint is needed. The
  client is not totally out of control or threatening others. However, ignoring the behavior will not result
  in a decrease in the lability.
  CN: Psychosocial integrity; CL: Synthesize

Answer 66

A

1. The nurse would excuse herself, showing respect and regard for the client, while telling the
  client to come to the dining room for lunch. Acutely manic clients need clear, concise comments and
  directions. Telling the client that he needs to stop talking because it’s lunchtime is disrespectful and
  does not give the client directions for what he needs to do. Using the familiar skill of waiting without
  interrupting until the person pauses would not be effective with the very talkative, manic client.
  Walking away and approaching the client after a few minutes before the food gets cold is not helpful
  because the client would probably continue talking.
  CN: Psychosocial integrity; CL: Synthesize

Answer 67

A

1. By stating to the client, “Swearing and profanity is unacceptable here,” the nurse is setting
  limits in a nonpunitive manner for behavior that is inappropriate or threatening to other clients and
  staff. Setting limits helps the client regain self-control, prevents alienation from others, and preserves
  self-esteem. It is common for the irritable manic client to misperceive the nurse’s and other’s
  statements and intentions, feel threatened, and respond in a manner that is out of character for the
  client when not in a manic phase. Stating that the client is acting very inappropriately or that the nurse
  will not tolerate the client’s swearing and profanity or threatening to put the client in seclusion is
  threatening and punitive and thus nontherapeutic.
  CN: Psychosocial integrity; CL: Synthesize

Answer 68

A

1. Stating that this must be difficult for the husband conveys empathy and understanding and
  offers him the opportunity to voice his feelings to the nurse. Telling the husband that it is okay and that
  the nurse has heard worse is inappropriate and minimizes the impact of the wife’s illness on the
  husband. Asking about the length of the client’s illness or telling the husband that his wife needs some
  medication ignores the husband’s feelings, thereby minimizing his self-respect.
  CN: Psychosocial integrity; CL: Synthesize

Answer 69

A

1. Telling the client that others may not want to hear about sex and inviting him to play a game
  of ping-pong with the nurse informs the client that even though his behavior is unacceptable, the nurse
  considers him worthy of help. The client’s thoughts and actions are out of control, and directing him to
  an activity with the nurse is an appropriate way of regaining control. The nurse is responsible for
  providing safety and security to this client and others on the unit. Continuing to walk down the hall
  while ignoring the conversation does nothing to meet the needs of this or other clients. Doing so also
  diminishes trust in the nurse. Speaking to the client later in private while saying nothing at the time
  allows the client to continue his provocative behavior instead of focusing his energy toward
  productive activity. Informing the client that if he continues to talk about sex, no one will want to be
  around him is not helpful because his behavior is a symptom of his illness and the statement
  diminishes his self-worth.CN: Psychosocial integrity; CL: Synthesize

Answer 70

A

1. The nurse suggests an activity such as walking around the unit to distract the client from the
  paranoid grandiose delusion that could result in loss of control. This action interrupts the client’s
  anxious state and helps to redirect energy and focus on an activity based in reality. The focus must be
  on the underlying need or feeling of the delusion and not on the content. Asking the client to describe
  the people who will come challenges the client and forces the client to cling to the delusion. Stating
  that the nurse and staff will protect the client conveys agreement with the client’s belief system,
  reinforcing the client’s delusion. Telling the client that he is not the prince of peace and repeating his
  name challenges the client and his present belief system. Doing so may lead to decreased trust in the
  nurse and an aggressive response, or it may force the client to defend his beliefs.
  CN: Psychosocial integrity; CL: Synthesize

Answer 71

A

1. The nurse needs to explain the procedure in simple terms because the client in a manic
  phase has difficulty concentrating, is easily distracted, and can misinterpret what the nurse states.
  Giving a thorough explanation of the procedure is not helpful and can confuse the client. Calling
  security to be on standby is inappropriate. If the nurse judges that the client might elope or become
  agitated, the nurse should schedule the appointment for another time. Canceling the appointment until
  the client can go unescorted is impractical and may not follow unit or hospital policy and the client’s
  treatment plan.
  CN: Psychosocial integrity; CL: Synthesize

Answer 72

A

1. The nurse escorts the client to her room and assists with choosing appropriate attire to
  preserve the client’s dignity and self-esteem and prevent ridicule from others on the unit. It is common
  for a client with bipolar disorder, manic phase, to exhibit poor judgment, provocative behavior, and
  hyperactivity. The client in the manic phase commonly dresses inappropriately and changes clothes
  many times throughout the day. The nurse needs to assist the client with hygiene, grooming, and proper
  attire until her judgment improves. Telling the client to dress appropriately while out of her room may
  be perceived by the client as an attack. Additionally, the client may be incapable of making that
  decision. Asking the client to put on hospital pajamas until she can dress appropriately is punitive and
  demeaning. Because of the client’s cognitive difficulties, the client may not understand the instructions
  to go to her room to change clothes. Additionally, the client may become distracted by stimuli on the
  unit and may not reach her room.
  CN: Psychosocial integrity; CL: Synthesize

Answer 73

A

1. While the client who is psychotic can upset other clients, the nurse must respond to the
  second client with both empathy for his feelings and a general explanation that the behavior is out of
  the psychotic client’s control. Agreeing with the second client or giving medication to the psychotic
  client does not help the complaining client gain empathy for his peer and only temporarily deals with
  the problem.
  CN: Psychosocial integrity; CL: Synthesize

Answer 74

A

1. The client with mania is very active and needs to have this energy channeled in a
  constructive task such as cleaning or tidying the dayroom. Because the client is distracted easily and
  can concentrate only for short periods, the successful completion of a helpful task would give the
  nurse the opportunity to thank the client for the help, thereby enhancing the client’s self-esteem.
  Leading a group activity is too stimulating for the client. Participating in this type of activity also maycause the client to be disruptive. Watching television or reading the newspaper would be
  inappropriate for the client who cannot sit for a period of time.
  CN: Psychosocial integrity; CL: Synthesize

Answer 75

A

1. The client in the manic phase experiences insomnia, as evidenced by his sleeping only for
  about 4 hours a night for the past 5 days. The client experiencing an acute manic episode is not
  capable of judging the need for sleep. Therefore, the nurse should assess the amount of rest the client
  is receiving daily to prevent exhaustion. The development of vertigo, gastritis, or bradycardia
  typically does not result from acute mania.
  CN: Psychosocial integrity; CL: Analyze

Answer 76

A

1. Bipolar disorder is a biochemical disorder caused by an imbalance of neurotransmitters in
  the brain. Manic episodes seem to be related to excessive levels of norepinephrine, serotonin, and
  dopamine. Psychopharmacologic therapy aims to restore the balance of neurotransmitters. In the past,
  it was thought that bipolar disorder may have been caused by early psychodynamics or disturbed
  families, but the current view emphasizes the role of biology. Bipolar disorder could be genetic or
  inherited from someone in the family, but it is best for the client and family to understand the disease
  concept related to neurotransmitter imbalance. This understanding also helps them to refrain from
  placing blame on anyone. Siblings and close relatives have a higher incidence of bipolar disorder
  and mood disorders in general when compared with the general population.
  CN: Psychosocial integrity; CL: Apply

Answer 77

A

1. The serum lithium level has nothing to do with the client’s white blood cell count and the
  drug manufacturers have no specific requirement for blood testing. While a periodic serum lithium
  level could monitor whether or not a client was taking the prescribed medication, the most important
  reason for the blood test is to periodically assess the client’s lithium level and prevent even mild
  toxicity on an ongoing basis.
  CN: Pharmacological and parenteral therapies; CL: Apply

Answer 78

A

1. Because lithium reaches peak blood levels in 1 to 3 hours, blood specimens for serum
  lithium concentration determinations are usually drawn before the first dose of lithium in the morning
  (which is usually 8 to 12 hours after the previous dose) or before breakfast. Stat lithium levels can be
  drawn at any time, usually when toxicity is suspected.
  CN: Pharmacological and parenteral therapies; CL: Apply

Answer 79

A

2, 3, 5. Serious side effects that may indicate lithium toxicity include muscle weakness,
vertigo, vomiting, extreme hand tremor, and sedation. The prescribing health care provider should be
notified immediately when these symptoms occur. When lithium is initiated, mild or transient side
effects can occur, such as nausea, fine hand tremor, anorexia, increased thirst and urination, and
diarrhea or constipation.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Answer 80

A

1. The therapeutic and toxic range of lithium is very narrow. If the client forgets to take a
  scheduled dose of lithium, the client needs to wait until the next scheduled time to take it, because
  taking twice the amount of lithium can cause lithium toxicity. The client needs to maintain a regular
  diet and regular salt intake. Lithium and sodium are eliminated from the body through the kidneys. An
  increase in salt intake leads to decreased plasma lithium levels because lithium is excreted morerapidly. A decrease in salt intake leads to increased plasma lithium levels. The client needs to drink 8
  to 10 eight-ounce glasses (240 to 300 mL) of water daily to maintain fluid balance and decrease
  thirst. Decreased water intake can lead to an increase in the lithium level and consequently a risk of
  toxicity. Lithium must be taken on a regular basis at the same time each day to ensure maximum
  therapeutic effect.
  CN: Pharmacological and parenteral therapies; CL: Evaluate

Answer 81

A

1. Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a
  benzodiazepine such as lorazepam (Ativan). Antipsychotic agents, such as Haldol, are prescribed to
  produce a neuroleptic effect until the lithium, which has a clinical response lag time of 1 to 2 weeks,
  produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is
  discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse
  would administer the drugs as prescribed.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Answer 82

A

1. The client’s statement, “I know I’m getting sick when I don’t need much sleep and start
  buying things,” indicates insight into her illness because the client recognizes symptoms that can lead
  to relapse. The statement, “I enjoy feeling high; I don’t need much sleep then and get really creative,”
  gives no indication that the client recognizes the detrimental effects of bipolar disorder. The
  statements about not needing medicine in another week or being cured indicate the client’s lack of
  understanding about the chronic nature of the disorder. The client is not cured from bipolar disorder,
  but symptoms of the disorder are usually managed when she is stabilized on medication. Medication
  may be needed by the client for many years or throughout her life.
  CN: Psychosocial integrity; CL: Evaluate

Answer 83

A

1. For this client, the nurse needs to set limits on the client’s intrusive, interruptive behavior
  by saying, “Please stop interrupting others; you can speak when it’s your turn.” This statement also
  clearly points out to the client the specific unacceptable behavior. The nurse helps the client to attain
  control and helps the other clients become more tolerant of the situation. Saying, “Stop talking; it’s
  time for you to leave the meeting,” is not helpful because it leaves the client unaware of what has
  happened or the behavior that is unacceptable. Also, such a statement may seem punitive. The
  statement, “If you can’t control yourself, we’ll have to take action,” is threatening to the client and
  diminishes the client’s self-worth. Using the statement, “Please behave like an adult. Your behavior is
  childish,” is demeaning and scolding to the client, thereby diminishing the client’s self-esteem.
  CN: Psychosocial integrity; CL: Synthesize

Answer 84

A

1. Valproic acid, an anticonvulsant agent, is used as a mood stabilizer in the client with
  bipolar disorder. Common side effects include drowsiness and gastrointestinal upset. The client
  needs to be cautioned not to drive or perform tasks requiring alertness and to take the medication with
  food or milk or eat frequent, small meals. Blood tests are required to evaluate the serum level and to
  check for possible hematologic effects. Valproic acid can cause changes in liver function and blood
  dyscrasias. The tablet must be swallowed whole and not chewed or crushed to prevent irritation of
  the mouth and throat. Alcohol as well as over-the-counter drugs and sleep-inducing agents must be
  avoided to prevent oversedation.
  CN: Pharmacological and parenteral therapies; CL: Create

Answer 85

A

1, 2, 5. The therapeutic level of valproic acid is 50 to 100 mg/mL (347 to 693 μmol/L). Alevel of 15 mg/mL (104 μmol/L) is not considered therapeutic. Therefore, the client would be
manifesting symptoms of mania. Irritability, euphoria, grandiosity, pressured speech, flight of ideas,
distractibility, and a decreased need for sleep are some characteristics of a manic episode.
Anhedonia and hypersomnia are related to a depressive illness and not mania.
CN: Pharmacological and parenteral therapies; CL: Analyze

Answer 86

A

1. The nurse should call the primary health care provider to report symptoms of a sore throat,
  fever, and chills because these symptoms may be signs of serious adverse effects of the medication,
  including potentially fatal hematologic, cardiovascular, and hepatic complications. Giving the dose of
  carbamazepine is contraindicated in this situation. Giving the acetaminophen would be inappropriate
  and potentially detrimental to the client’s health. Waiting until morning to report the client’s symptoms
  is a serious error in judgment.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Answer 87

A

1. The nurse’s most appropriate action is to give the wife information about a support group in
  her area. Family members need and want education and support. Suggesting that the wife see a
  primary health care provider is not necessary in this situation. She needs support and education.
  Recommending that she talk with her close friend may be helpful if she so chooses. However, this is
  not as helpful as attending a support group. Here the wife can learn, share, obtain support from, and
  provide support to others with similar situations. Having the wife share her feelings with her husband
  may or may not be appropriate or helpful to her or her husband. The husband may be unable to help
  his wife with adaptive coping, and therefore the client’s self-esteem could be diminished.
  CN: Psychosocial integrity; CL: Synthesize

Answer 88

A

1. The nurse should encourage the husband to support and communicate openly with his wife
  to maintain effective family-client interactions. During any illness, open communication and support
  helps the relationship between husband and wife. It is unrealistic for any individual to be free from
  anxiety or worry and impossible for the husband to be able to control what his wife may think or feel.
  Relieving the client of all responsibilities is unrealistic and not helpful. The client needs to resume
  activities as soon as she can manage them. Reminding his wife to control her symptoms is not
  appropriate and indicates that the husband needs further teaching about this condition.
  CN: Psychosocial integrity; CL: Create

Answer 89

A

89.
3. Take client to a quiet area, such as his or her room, to decrease stimuli.
1. Use oral medication to decrease anxiety and increase appropriate social interaction.
2. Talk with the client about the anxiety and stress the client is feeling.
4. Teach the client coping strategies to deal with stressors.
None of the other interventions will be successful unless the stimuli that fuel the client’s mania areremoved or decreased. Once the client is in a quieter setting, oral medication will help calm the
client so he or she can be calmer. Once the medication has taken effect, the nurse can help the client
explore the client’s feelings and problem. Finally, teaching coping techniques can be effective to
address client problems after he or she has become calmer.
CN: Psychosocial integrity; CL: Synthesize

Answer 90

A

1. The nurse should state her name and purpose on the unit to clarify her identity and to
  counteract other beliefs the client may have. Stating that the nurse doesn’t want to or can’t go out to
  dinner is not therapeutic because it fails to clarify the client’s misperceptions or erroneous beliefs, as
  is the statement, “It doesn’t matter how I look, the answer is no.”
  CN: Psychosocial integrity; CL: Synthesize

Answer 91

A

1. The client is visibly out of control, and other measures have not helped. Therefore, the
  nurse needs to seclude the client and use restraints if necessary to protect the client and others from
  harm. Following the client and asking her to calm down or telling the client to lie down on the sofa is
  not helpful because the client’s level of anxiety is too high for her to attempt to calm down on her own
  and she cannot control her behavior. Telling the staff to ignore the client’s remarks is not helpful
  because the client needs external means of control to protect the client, other clients on the unit, and
  the staff. Safety is the priority.
  CN: Safety and infection control; CL: Synthesize

Answer 92

A

1. When the client in a manic state attempts to manipulate the nurse or demands privileges, the
  nurse must restate the unit rules in a calm and matter-of-fact manner. “The television hours are from 7
  PM to 10 PM . It is 10 PM , and the television goes off so everyone can sleep” is the most therapeutic
  response because it restates the rules and is nonthreatening. During a manic phase, the client is
  impulsive and has difficulty concentrating. The client needs consistency and structure from the staff.
  The statement, “I’ll let you watch television just this once; don’t tell anyone about this,” allows the
  client to manipulate the nurse, as does “I’ll turn the television off when you get sleepy. Don’t ask me to
  do this again.” In addition, the last portion of the statement is a threat. The statement, “The television
  goes off at 10 PM ; I’ve been telling you this for the past three evenings,” is inappropriate because it is
  authoritative and demeaning to the client.
  CN: Psychosocial integrity; CL: Synthesize

Answer 93

A

The Client with Suicidal Ideation and Suicide Attempt
93. 1, 2, 4. Having resources such as a crisis phone line number and a specific prevention plan
helps clients know what to do if they begin to feel they want to harm themselves. Likewise, having
support people educated about how to help the client stay safe also improves the client’s safety. Not
all medications are lethal enough that access to a month’s supply of medication should be limited.
Further, such a limitation is likely to increase costs for the clients, which may increase the client’s
stress. It is unrealistic and potentially distressing to the client and family/friends to have the client
under constant surveillance.
CN: Safety and infection control; CL: Apply

Answer 94

A

1. Assessing for suicide risk in the ED is important because suicidal clients can be discharged
  without being assessed for suicide potential. Many visitors to the ED are there for comprehensive
  health care needs and lack primary care providers. It is a myth that talking about suicide will causeyoung people to think about suicide, and evidence exists that they will talk about suicide if asked
  directly. Assessing adults only because they will be more honest is an incorrect assumption. Limiting
  the assessment of suicide risk only to adolescents with psychiatric diagnoses falsely assumes that
  other young people are not at risk for suicide. Questioning the parents about their adolescent’s suicide
  risk may be an unreliable method because the parents may not be aware that suicide risk is present.
  CN: Psychosocial integrity; CL: Synthesize

Answer 95

A

1. A crucial factor in determining the lethality of a method is the amount of time that occurs
  between initiating the method and the delivery of the lethal impact of the method. Lethal methods of
  suicide include using a gun, jumping from a high place, hanging, drowning, carbon monoxide
  poisoning, and overdose with certain drugs, such as central nervous system depressants, alcohol, and
  barbiturates. The more detailed the suicide plan, the more lethal and accessible the method, and the
  more effort exerted to block rescue, the greater the chance is for the suicide to be completed.
  Impulsive attempts at suicide even with rescuers in sight may be lethal depending on the method. Less
  lethal methods may include overdosing on aspirin and wrist cutting. Head-banging is a self-injurious
  behavior that requires intervention and is not to be taken lightly; however, it is not considered a lethal
  method of suicide.
  CN: Psychosocial integrity; CL: Apply

Answer 96

A

1. The statement, “No matter what the intent, all suicidal behavior is serious and deserves our
  serious consideration,” is most appropriate because it provides accurate information for the staff.
  Superficial cuts may be termed suicide gestures. Nevertheless, they still are a cry for help and may
  indicate ambivalence about dying. Clients have accidentally and unintentionally killed themselves
  because previous attempts were not taken seriously, they acted on impulse, or rescue attempts were
  foiled. Stating, “It’s our job to help her no matter how we feel about her or what she did; she’ll be
  discharged soon,” is inappropriate because it does not provide the staff members with accurate
  information. Stating, “I won’t tolerate that kind of discussion from my staff; now it is time for you to
  go back to work,” is authoritarian and punitive. Additionally, it does not help the staff members gain
  insight. Stating, “I know it’s hard to understand, but we need to do the best we can even though she’ll
  be back,” voices agreement with the staff’s bias and lack of knowledge. As such, this statement is
  inappropriate.
  CN: Management of care; CL: Synthesize

Answer 97

A

1. On hearing the client’s statement, the nurse must ask the client directly if she plans to kill
  herself. It is erroneous to think that talking to the client about suicide will drive her to it. Asking
  directly about suicidal intent is absolutely necessary. Commonly, doing so provides the client with a
  sense of relief. In addition, the nurse conveys concern for and a sense of worth to the client, thus
  enabling appropriate planning for care. Asking “What do you mean?” is an indirect method of inquiry
  that provides the client with the opportunity to evade the nurse’s intent. Asking “Doesn’t your family
  care about you?” shows poor judgment on the nurse’s part and is demeaning to the client. Asking
  “What happened to make you think that?” conveys a lack of knowledge of psychopathology.
  CN: Psychosocial integrity; CL: Analyze

Answer 98

A

1. For the client with suicidal ideation, client safety is the priority. The nurse protects the
  client from self-harm or self-destruction. Although self-esteem, sleep, and hygiene are common areas
  that require intervention for a client with suicidal ideation, ensuring the client’s safety is the mostimmediate and serious concern.
  CN: Safety and infection control; CL: Synthesize

Answer 99

A

1. To determine the seriousness of the suicidal ideation, the nurse must ask directly about the
  intent and the plan. The nurse needs to determine whether the client has a concrete plan and will act
  on his thoughts. Then the nurse assesses the lethality of the method, immediacy, means to complete
  suicide, and possibility of rescue. Asking the client, “Have you made out a will?” is not as important
  and does not necessarily imply that he is planning self-harm. Many individuals have made out wills
  without planning self-harm. Asking the client, “Does your family know you’re here?” provides no
  information about the client’s intent and plan. Asking the client, “How long have you been thinking
  about harming yourself?” does provide information that the client is thinking about self-harm.
  However, it does not provide information about the client’s immediate intent and plan.
  CN: Psychosocial integrity; CL: Analyze

Answer 100

A

1. The nurse’s best response is to teach the nursing assistant about the appropriate
  intervention and why it is important for the client. Staff members need to be client focused and to
  understand why a specific intervention is important and appropriate. Telling the assistant that the
  assignment will be switched or not to worry about it is not appropriate because it does not teach the
  nursing assistant about the client’s illness and appropriate client care. The statement, “Clients who are
  depressed are hard to deal with, but don’t take what they say seriously,” does not help the staff
  member understand why listening is important and may jeopardize the client’s safety.
  CN: Management of care; CL: Synthesize

Answer 101

A

1. The immediate priority is to save the caller’s life. Therefore, the nurse should tell the
  caller that another nurse will telephone the police. The immediate goal is to rescue the caller because
  the suicide attempt has begun. Referring the caller to a 24-hour suicide hotline or instructing the caller
  to telephone her family for help may be appropriate as part of discharge planning. Asking the caller
  whether she has telephoned her primary health care provider is not appropriate. The nurse is
  responsible for notifying the primary health care provider.
  CN: Psychosocial integrity; CL: Synthesize

Answer 102

A

1. The statement refers to the suicidal client’s wish to use her own death to retaliate or get
  even with her boyfriend. If a client wishes to retaliate, discovering the specific plans would be
  important to maintaining her safety as well as possibly her boyfriend’s. Though sadness, escape, and
  loneliness can all be themes expressed by a suicidal client, they do not apply to the comment made by
  this client.
  CN: Psychosocial integrity; CL: Analyze

Answer 103

A

1. The statement, “I don’t think about killing myself as much as I used to,” indicates a
  lessening of suicidal ideation and improvement in the client’s condition. The statement, “I couldn’t kill
  myself because I don’t want to go to hell,” indicates that the client will not attempt suicide but could
  still be thinking about death. The statements “I’m of no use to anyone anymore” and “I know my kids
  don’t need me anymore since they’re on their own” indicate that the client feels worthless and may be
  experiencing suicidal ideation.
  CN: Psychosocial integrity; CL: Evaluate

Answer 104

A

1. Based on the client’s statement, the nurse must initiate plans for hospitalizationimmediately because the client has suicidal ideation with a definite plan, lethal method, and
  immediate access to the method.
  CN: Psychosocial integrity; CL: Synthesize

Answer 105

A

1. The survivor of suicide, in this situation, would be referred to a group for survivors of
  suicide to help her with her feelings and to work through the grief reaction. This group provides
  support and understanding of what the individual is experiencing by members who are experiencing
  similar reactions, including anger and guilt. Depression and unresolved grief can occur when the
  survivor does not receive appropriate help. Counseling by a chaplain or individual therapy by the
  nurse may be appropriate in addition to referral to the group. Giving the survivor the suicide hotline
  number would be appropriate if the survivor herself were thinking about suicide.
  CN: Psychosocial integrity; CL: Synthesize

Answer 106

A

1. The most appropriate response is to discuss the behavioral clues and resources because it
  provides the husband with important information that he needs to cope with his wife’s condition.
  Family members are commonly afraid of future suicidal activity and need helpful information and
  resources to turn to in a crisis. Telling the husband not to worry minimizes the husband’s concern and
  is not necessarily true. Additionally, past suicide attempts need to be considered when evaluating the
  client’s future risk of suicide. The statement, “She told me she wants to live so I don’t think she’ll try
  again,” ignores the husband’s request and concerns. Additionally, there is no way for the nurse to
  know whether the client will attempt suicide again. The statement, “Tell her about your concern and
  just take care of her,” is not helpful because the husband needs information and resources to turn to
  should a crisis develop.
  CN: Psychosocial integrity; CL: Synthesize

Answer 107

A

1. After the client identifies and shares her strengths, the nurse reinforces the client for her
  ability to evaluate herself in a positive manner. Doing so promotes self-esteem and offers hope for
  improvement. Asking the client to identify three additional strengths or volunteering the client to lead
  the cooking group could be too overwhelming for the client at this time and may increase her anxiety
  and feelings of worthlessness. Although educating the client about the importance of medication is
  important, doing so at another time would be more appropriate.
  CN: Psychosocial integrity; CL: Synthesize

Answer 108

A

1. The best response would be for the nurse to advise the visitor to be caring and genuine to
  the client as a friend normally would. Family and friends are commonly afraid or at a loss about how
  to act or what to say to someone with a mental illness or to someone who may voice thoughts of self-
  harm. The statement, “Try to cheer her up,” is inappropriate because the client may feel overwhelmed
  and thus become more despondent when she cannot meet or match the cheerful demeanor. The
  statement, “Control your expressions,” is inappropriate because the client is not helped when
  interactions are not natural and genuine. The statement, “Avoid asking how she’s feeling,” is
  inappropriate because it conveys a lack of interest in and concern for the client.
  CN: Psychosocial integrity; CL: Synthesize

Answer 109

A

1. The client with feelings of self-doubt, inability to control her life, and dependency is
  manifesting problems evident in autonomy versus shame/doubt. Because of illness, regression has
  occurred and the client’s behaviors affect how the nurse will intervene with the client. With trust
  versus mistrust, some behaviors reflecting problems include suspiciousness, projection of blame, andwithdrawal from others. With initiative versus guilt, some behaviors reflecting problems include
  excessive guilt, reluctance to show emotions, and passivity. With industry versus inferiority, some
  behaviors reflecting problems include feelings of being unworthy, poor work history, and inadequate
  problem-solving skills.
  CN: Psychosocial integrity; CL: Analyze

Answer 110

A

1. The nurse should arrange for a psychiatric home care nurse to visit the client and follow
  her care. The psychiatric home care nurse will help the client manage her psychiatric disorder,
  medications for her mental illness and diabetes, diabetic care, and nutrition. A medical social worker
  may be involved with the client’s care after discharge to help with interactions among agencies and
  visits by clergy may be helpful, but a psychiatric home care nurse would be most important to help the
  client manage the many needs associated with her illness. An occupational therapist could help the
  client consider home management adjustments that might be needed after discharge but no ongoing
  disability is noted.
  CN: Management of care; CL: Apply

Answer 111

A

1. Client safety is the priority to prevent further self-harm. Nutrition, sleep, and hygiene are
  important concerns, but they are secondary to safety.
  CN: Safety and infection control; CL: Analyze

Answer 112

A

1. The nurse inspects the bag and its contents in the presence of the client and his wife so that
  they know what is allowed on the unit and what should be returned home and why. The nurse is
  responsible for the client’s safety and that of the other clients and staff. Telling the wife to take her
  husband’s things home because he is suicidal diminishes the client’s self-worth and is inaccurate.
  Instructing the wife to unpack the bag and put her husband’s things away is inappropriate because it is
  the nurse’s responsibility to manage safety issues pertaining to the client and the unit. Asking the wife
  whether the bag contains anything dangerous would be poor judgment on the part of the nurse because
  the wife would not be knowledgeable about the safety factors.
  CN: Psychosocial integrity; CL: Synthesize

Answer 113

A

1. The nurse and staff should place the client in leather restraints to protect her from further
  self-harm. The client’s behavior is out of control and necessitates external controls for her safety.
  Telling the client to stop and act like a responsible adult is ineffective and not therapeutic. Calling the
  primary health care provider for additional medication prescriptions is not appropriate because the
  lorazepam (Ativan) given by the nurse may take effect if the client remains still. The nurse is
  responsible for judging whether additional medication is needed later. Instructing a staff member to
  sit in the room with the client is unsafe for the client and the staff member.
  CN: Safety and infection control; CL: Synthesize

Answer 114

A

1. The nurse needs to ask the client whether he is going to hurt himself to determine the
  client’s ability to cope with the voices and to assess the client’s impulse control. The nurse’s
  assessment will then determine the course of action to take regarding the client’s safety. Asking when
  the client hears the voices and how long the client has heard them is important but not as important as
  determining whether the client will act on what the voices are saying. Asking “Why are the voices
  starting again?” would be inappropriate because the client may not know why and may not be able to
  answer the nurse.CN: Safety and infection control; CL: Analyze

Answer 115

A

1. Though disturbed thoughts and sensory perceptions would be a concern to the nurse, as
  would communication issues, the primary issue for this client in terms of his comments would be the
  potential for medication noncompliance and relapse. Most college students want to be like their peers
  and perceive themselves as capable and well. These beliefs can lead a young client with
  schizophrenia to stop taking medication, which leads to relapse.
  CN: Psychosocial integrity; CL: Synthesize

Answer 116

A

1. Clients on 15-minute suicide checks must be observed by a staff member every 15
  minutes. However, the staff member must stagger the timing of the check so that the client cannot
  predict the precise time. The staff member could check the client at 10 minutes and then at 8 minutes,
  and so on, to protect the client from self-harm. The nurse would further explain the necessity of this
  procedure to help the staff understand its importance. Documenting that suicide checks have been
  done is absolutely necessary. Clients on one-to-one suicide precautions can never be left alone. All
  clients using razors must be supervised by staff.
  CN: Management of care; CL: Evaluate

Answer 117

A

1. Talking with a staff member when suicidal thoughts occur is an important part of
  contracting for safety. The nurse or another staff member can then assess whether the client will act on
  the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a
  journal, reading, or playing games with others does not allow the client to verbalize suicidal thoughts
  to the nurse.
  CN: Safety and infection control; CL: Synthesize

Answer 118

A

1. Because the client has a history of recurring depression and suicidal ideation, the nurse
  would give the client a 7-day supply of imipramine to prevent possible overdose. Giving the client a
  14-, 21-, or 30-day supply of medication would provide the client with enough medication to
  complete a suicide attempt. Tricyclic antidepressants are associated with a higher rate of death than
  are selective serotonin reuptake inhibitors.
  CN: Pharmacological and parenteral therapies; CL: Apply

Answer 119

A

1. Because the client is in danger of noncompliance with the medication due to financial
  concerns, the nurse should contact the social worker to assist with locating available resources for
  the client to ensure continuation of the medication needed for the recurrent illness. The client needs to
  continue the medications with no interruptions to minimize the chance of decompensation. Although
  the primary health care provider is the person responsible for prescribing the client’s medication,
  routinely the primary health care provider is not involved in finding financial assistance for the
  client’s medication needs. The client needs the medication at the present time. Three months is too
  long to wait for a follow-up appointment. The client could be severely depressed and could even
  attempt suicide. A family member’s assistance may not be a sufficient or a permanent means of
  financial help for the client in terms of medication needs.
  CN: Management of care; CL: Synthesize

Answer 120

A

1. Statistics do not apply when you are focused on one individual and every depressed client
  is potentially suicidal. During the most severe symptom period, the individual often does not have the
  energy to act on his or her suicidal ideation. The majority of people who complete suicide havetalked about it or left clues to their intention. During the initial treatment period, the risk for suicide
  may be higher due to the delay of therapeutic onset.
  CN: Psychosocial integrity; CL: Analyze

Answer 121

A

Managing Care Quality and Safety
121. 3. Distraction and disorganization may prevent clients from eating or sleeping. Monitoring
for needed intervention can prevent exhaustion and malnutrition. Liquid medications are indicated
only if the client cannot or will not swallow tablets. Manic clients tend to disrupt group therapy, so
this treatment usually is not for them. Family visits should not be tied to compliance with treatment.
The client is unlikely to be able to concentrate and complete a journal at this time.
CN: Psychological integrity; CL: Synthesize

Answer 122

A

1. The statement by the person who says “I have found a solution for this mess” contains
  suicidal ideation and that person is more of a safety risk than the angry, alienated client or the
  obsessed or helpless one. The other clients may need intervention as well, but the potentially suicidal
  client has the greatest need for nursing intervention.
  CN: Management of care; CL: Analyze

Answer 123

A

1. The nurse communicates with consulting primary health care providers and referral
  agencies as part of the client’s continuity of care to which the client consented when admitted to the
  unit. The communication with family also has the client’s consent. The communication with someone
  outside the care team without the client’s permission (talking to a friend) is a breach of ethics by the
  nurse.
  CN: Management of care; CL: Apply

Answer 124

A

1. It is important for the nurse to listen to the client and respect their knowledge about their
  medication. In the other options, the nurse dismisses the client’s concern or gives a possible
  explanation without checking out the specific situation. If the nurse has taken the wrong medication,
  the client can prevent a medication error, and if there has been a color change, the nurse can let the
  client know that information. In either case, helping a psychotic client deal with reality appropriately
  is therapeutic.
  CN: Safety and infection control; CL: Synthesize

Answer 125

A

1. The nurse should question the Tylenol prescription because the client overdosed on
  Tylenol, and that analgesic would be contraindicated as putting further stress on the liver. There is no
  need to hold the PM milk of magnesia or Maalox. There is no indication that the client is agitated or
  needs medication for agitation. There is little likelihood that the client needs an IV after being
  transferred out of an intensive care unit, as the client will be able to take oral fluids.
  CN: Pharmacological and parenteral therapies; CL: Synthesize

Answer 126

A

1. High-risk factors that have been related to suicide include hopelessness, Caucasian race,
  male gender, advanced age, living alone, previous suicide attempts, family history of suicide
  attempts, family history of substance abuse, general medical illnesses, psychosis, and substance
  abuse. The highest suicide rate is among people over the age of 65, particularly Caucasian males age
  85 and over. Psychiatric diagnosis is considered to be the most reliable factor for suicide, especially
  for those with depression, schizophrenia, and substance disorders. Therefore, an 85-year-oldCaucasian male who lives alone after his wife’s death is at high risk for suicide completion.
  CN: Management of care; CL: Analyze

Answer 127

A

1, 3, 4, 5. Exploring the bullying and giving the student resources as well as planning for his
safety will help the client remain safe. Notifying the school is essential to ensuring the safety of other
students in the community. Notifying the parents against the client’s wishes destroys trust and could
make him feel more desperate. A better action would be to help the student prepare to reveal his
sexual orientation to his parents.
CN: Management of care; CL: Create

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