Exam II Flashcards
A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?
A.
Administering lorazepam (Ativan) prn, because the client is angry at exposure of plan.
B.
Establishing room restrictions, because the client’s threat is an attempt to manipulate the staff.
C.
Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.
D.
Calling an emergency treatment team meeting, because the client’s threat must be addressed.
C
In planning care for a suicidal client, which outcome should be a nurse’s first priority?
A.
The client will not physically harm self.
B.
The client will express hope for the future by day 3.
C.
The client will establish a trusting relationship with the nurse.
D.
The client will remain safe during hospital stay.
D
A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment. What is the nurse’s rationale for this procedure?
A.
To prevent increased intracranial pressure resulting from anoxia.
B.
To prevent decreased blood pressure, pulse, and respiration due to electrical stimulation.
C.
To prevent anoxia due to medication-induced paralysis of respiratory muscles.
D.
To prevent blocked airway, resulting from seizure activity.
C
Immediately after electroconvulsive therapy, in which position should a nurse place the client?
A.
On his or her side to prevent aspiration.
B.
In high Fowler’s position to promote consciousness.
C.
In Trendelenburg’s position to promote blood flow to vital organs.
D.
In prone position to prevent airway blockage.
A
A client is diagnosed with dysthymic disorder. Which symptom should a nurse classify as an affective symptom of this disorder?
A. Social isolation with a focus on self. B. Low energy level. C. Difficulty concentrating. D. Gloomy and pessimistic outlook on life.
D
A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder?
A.
Altered communication R/T feelings of worthlessness AEB anhedonia.
B.
Social isolation R/T poor self-esteem AEB secluding self in room.
C.
Altered thought processes R/T hopelessness AEB persecutory delusions.
D.
Altered nutrition: less than body requirements R/T high anxiety AEB anorexia.
B
A client diagnosed with major depression with psychotic features hears voices commanding self-harm. A nurse is unable to elicit a contract for safety. What should be the nurse’s priority intervention at this time?
A.
Obtaining an order for locked seclusion until client is no longer suicidal.
B.
Conducting 15-minute checks to ensure safety.
C.
Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
D.
Encouraging client to express feelings related to suicide.
C
A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis?
A.
The client is disheveled and malodorous.
B.
The client refuses to interact with others.
C.
The client is unable to feel any pleasure.
D.
The client has maxed-out charge cards and exhibits promiscuous behaviors.
D
A client with a history of suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse’s priority at this time?
A.
Give the client off-unit privileges as positive reinforcement.
B.
Encourage the client to share mood improvement in group.
C.
Increase the level of this client’s suicide precautions.
D.
Request that the psychiatrist reevaluate the current medication protocol.
C
A nurse reviews the laboratory data of a client suspected of having major depressive disorder. Which lab value would potentially rule out this diagnosis?
A. Thyroid-stimulating hormone (TSH) level of 0.25 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL
A
A depressed client reports a history of divorce, job loss, family estrangement, and cocaine abuse to a nurse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?
A.
According to psychoanalytic theory, depression is a result of anger turned inward.
B.
According to object-loss theory, depression is a result of abandonment.
C.
According to learning theory, depression is a result of repeated failures.
D.
According to cognitive theory, depression is a result of negative perceptions.
C
What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder?
B
A.
The attention during the assessment is beneficial in decreasing social isolation.
B.
Depression can generate somatic symptoms that can mask actual physical disorders.
C.
Physical health complications are likely to arise from antidepressant therapy.
D.
Depressed clients avoid addressing physical health and ignore medical problems.
B
A nurse is planning care for a child who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in children and adolescents?
A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)
D
A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam?
A. To rule out bipolar disorder. B. To rule out schizophrenia. C. To rule out senile dementia. D. To rule out a personality disorder.
C
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client’s safety upon discharge?
A.
Provide a 6-month supply of Elavil to ensure long-term compliance.
B.
Provide a 1-week supply of Elavil with refills contingent on follow-up appointments.
C.
Provide pill dispenser as a memory aid.
D.
Provide education regarding the avoidance of foods containing tyramine.
B
An older client has recently been prescribed sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?
A.
Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs).
B.
Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI).
C.
Serotonin syndrome possibly caused by ingestion of an SSRI and an MAOI.
D.
Serotonin syndrome possibly caused by ingestion of two different SSRIs.
D
A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing response?
A.
“This combination of drugs can lead to delirium tremens.”
B.
“A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.”
C.
“That’s a good idea. There have been good results with the combination of these two drugs.”
D.
“The only disadvantage would be the exorbitant cost of the MAOI.”
B
A psychiatrist prescribes a monoamine oxidase inhibitor for a client. Which foods should the nurse teach the client to avoid?
A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola
A
A highly agitated client paces the unit and states, “I could buy and sell this place.” The client’s mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client’s behavior?
A.
“Rates mood 8/10. Exhibiting looseness of association. Euphoric.”
B.
“Mood euthymic. Exhibiting magical thinking. Restless.”
C.
“Mood labile. Exhibiting delusions of reference. Hyperactive.”
D.
“Agitated and pacing. Exhibiting grandiosity. Mood labile.”
D
A client diagnosed with bipolar disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?
A.
Knowledge deficit R/T bipolar disorder AEB concern about symptoms.
B.
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss.
C.
Risk for suicide R/T powerlessness AEB insomnia and anorexia.
D.
Altered sleep patterns R/T mania AEB insomnia for the past 3 nights.
B
A nurse is planning care for a client diagnosed with bipolar disorder: manic phase. In which order should the nurse prioritize the client outcomes in the exhibit? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night.
A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3
C
A client diagnosed with bipolar disorder: depressive phase intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?
A. Risk for suicide R/T hopelessness. B. Anxiety: severe R/T hyperactivity. C. Imbalanced nutrition: less than body requirements R/T refusal to eat. D. Dysfunctional grieving R/T loss of employment.
A
A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate due to excessive weight gain. In order to increase compliance, which medication should a nurse anticipate that a physician will prescribe?
A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)
B
A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa order. Which is the appropriate nursing response?
A.
“Zyprexa in combination with Eskalith cures manic symptoms.”
B.
“Zyprexa prevents extrapyramidal side effects.”
C.
“Zyprexa ensures a good night’s sleep.”
D.
“Zyprexa calms hyperactivity until the Eskalith takes effect.”
D
A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing response?
A.
“That’s strange. Weight loss is the typical pattern.”
B.
“What have you been eating? Weight gain is not usually associated with lithium.”
C.
“Weight gain is a common, but troubling, side effect.”
D.
“Weight gain only occurs during the first month of treatment with this drug.”
C
A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?
A.
“This disorder is more prevalent in the lower socioeconomic groups.”
B.
“This disorder is more prevalent in the higher socioeconomic groups.”
C.
“This disorder is equally prevalent in all socioeconomic groups.”
D.
“This disorder’s prevalence cannot be evaluated based on socioeconomic groups.”
B
A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithane) for 1 year. The client presents in an emergency department with a temperature of 101?F (38?C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
A.
Symptoms indicate consumption of foods high in tyramine.
B.
Symptoms indicate lithium carbonate discontinuation syndrome.
C.
Symptoms indicate the development of lithium carbonate tolerance.
D.
Symptoms indicate lithium carbonate toxicity.
D
What tool should a nurse utilize to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?
A. “Risky Activity” tool B. “FIND” tool C. “Consensus Committee” tool D. “Monotherapy” tool
B
A client diagnosed with bipolar disorder weighs 220 lb. A physician orders lamotrigine (Lamictal) 10 mg/kg/day to a maximum of 400 mg/day for mood stabilization. Which is a true statement about this medication order?
A.
This calculated dosage is within the recommended dosage range.
B.
This calculated dosage is lower than the recommended dosage range.
C.
This calculated dosage is more than twice the recommended dosage range.
D.
This calculated dosage is four times higher than the recommended dosage range.
C
A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?
A.
“Treatment is compromised when clients can’t sleep.”
B.
“Treatment is compromised when irritability interferes with social interactions.”
C.
“Treatment is compromised when clients have no insight into their problems.”
D.
“Treatment is compromised when clients choose not to take their medications.”
D
A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 lb by the end of the week?”
A.
Provide client with high-calorie finger foods throughout the day.
B.
Accompany client to cafeteria to encourage adequate dietary consumption.
C.
Initiate total parenteral nutrition to meet dietary needs.
D.
Teach the importance of a varied diet to meet nutritional needs.
A
A nursing instructor is teaching about specific phobias. Which student statement should indicate to the instructor that learning has occurred?
A.
“These clients recognize that their fear is excessive and seek treatment to promote change.”
B.
“These clients have a panic level of fear that is overwhelming and unreasonable.”
C.
“These clients experience symptoms that mirror a cerebrovascular accident (CVA).”
D.
“These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.”
B
A client has a history of excessive fear of water. What is the term that a nurse should use to describe the specific phobia, and what is the subtype of the specific phobia?
A.
Aquaphobia, a natural environment type of phobia.
B.
Aquaphobia, a situational type of phobia.
C.
Acrophobia, a natural environment type of phobia.
D.
Acrophobia, a situational type of phobia.
A
