Mood Disorders NCLEX Questions with Rationale

NCLEX Mood Disorders Questions

Mood Disorders NCLEX Practice Questions

Question 1.
The nurse is planning care with a Latino client who is diagnosed with a depressive disorder. The client uses treatment by a root healer. Which intervention is most indicated?
(a) Avoid talking to the client about the root healer.
(b) Explain to the client that Western medicine has a scientific, not mystical, basis.
(c) Explain that such beliefs are superstitious and should be forgotten.
(d) Involve the root healer in a consultation with the client, health care provider, and nurse.
Answer:
(d) Involve the root healer in a consultation with the client, health care provider, and nurse.

Explanation:
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 also is likely to alienate and cause the client to end treatment.

Question 2.
After a period of unsuccessful treatment with amitriptyline, a client diagnosed with depression is switched to tranylcypromine. Which statement by the client indicates the client understands the side effects of tranylcypromine?
(a) “I need to increase my intake of sodium.”
(b) “I must refrain from strenuous exercise.”
(c) “I must refrain from eating aged cheese or yeast products.”
(d) “I should decrease my intake of foods containing sugar.”
Answer:
(c) “I must refrain from eating aged cheese or yeast products.”

Explanation:
Cheese and yeast products contain tyra- mine, which the client should avoid to prevent a negative interaction with tranylcypromine, a mono¬amine oxidase (MAO) inhibitor. Sodium will not interact with tranylcypromine, and neither exercise nor sugar needs to be limited.
 
Question 3. 
A client is scheduled for the first electroconvulsive therapy (ECT) treatment in the morning and has been unable to sleep. In what order should the nurse perform the interventions from first to last? All options must be used.
(a) Sit quietly with the client.    
(b) Encourage the use of prescribed PRN temazepam.
(c) Offer use of an audio recording with relaxing music.
(d) Discuss specific concerns.
Answer:
(a) Sit quietly with the client.    
(c) Offer use of an audio recording with relaxing music.
(d) Discuss specific concerns.
(b) Encourage the use of prescribed PRN temazepam.

Explanation: 
(a), (c), (d), (b) The client is likely anxious about the ECT 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.

Question 4.    
A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client’s scalp. Which referral should the nurse make first?
(a) occupational therapist
(b) physical therapist
(c) psychologist
(d)  a health care provider
Answer:
(d)  a health care provider

Explanation:
The client is exhibiting signs of hypothyroidism, which includes hair loss, pain, fatigue, and increased sensitivity to cold. Hypothyroidism may be impacting the client’s mood, ability to concentrate, physical sensations, and energy levels. Resolving potential biological causes of her symptoms takes priority over rehabilitation strategies or psychological approaches.

Question 5.
A client has been taking 30 mg of duloxetine 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?
(a) Refer the client to the concurrent disorders program at the clinic.
(b) Share the information at the next interdisciplinary treatment conference.
(c) Report the client’s beer consumption to the health care provider (HCP).
(d)  Teach the client relaxation exercises to perform before bedtime.
(e) A client was admitted to the inpatient unit
Answer:
(c) Report the client’s beer consumption to the health care provider (HCP).

Explanation:
The nurse should report the client’s beer consumption to the HCP UJ. 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 concurrent diagnosis program, sharing informa-tion 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 HCP is most important.

Question 6.
3 days ago with a flat affect, psychomotor deficits, anorexia, hopelessness, and suicidal ideation. The health care provider prescribed 75 mg of venlafax- ine extended release to be given every morning. The client interacted minimally with the staff and spent most of the day in his room. At the beginning of the shift, the nurse observes that 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?
(a) The venlafaxine is helping the client’s symptoms of depression significantly.
(b) The client’s sudden improvement calls for close observation by the staff.
(c) The staff can decrease their observation of the client.
(d) The client is nearing discharge due to the improvement of his symptoms.
Answer:
(b) The client’s sudden improvement calls for close observation by the staff.

Explanation:
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 antidepres-sants 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.

Question 7.
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?
(a) “My husband will slowly feel better as his medicine takes effect over the next 2 to 4 weeks.”
(b) “My wife will need to take her antidepressant medicine and go to group to stay well.”
(c) “My son will only need to attend outpatient appointments when he starts to feel depressed again.”
(d)  “My mother might need help with grocery shopping, cooking, and cleaning for a while.”
Answer:
(c) “My son will only need to attend outpatient appointments when he starts to feel depressed again.”

Explanation:
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.

Question 8.
A 16-year-old client is prescribed 10 mg of paroxetine at bedtime for major depression. The nurse should instruct the client and parents to monitor the client closely for which adverse effect?
(a) headache
(b) nausea
(c) fatigue
(d)  agitation
Answer:
(d)  agitation

Explanation:
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 are transient adverse effects of paroxetine. 

Question 9.
A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which approach by the nurse is most therapeutic?
(a) Wait for the client to begin the conversation.
(b) Initiate contact with the client frequently.
(c) Sit outside the client’s room.
(d)  Question the client until the client responds.
Answer:
(b) Initiate contact with the client frequently.

Explanation:
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 worth-while 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.

Question 10. 
The client exhibits a flat affect, psychomotor deficits, 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?
(a) “I’ll sit here with you for 15 minutes.”
(b) “I’ll come back a little bit later to talk.”
(c) “I’ll find someone else for you to talk with.”
(d)  “I’ll get you something to read.”
Answer:
(a) “I’ll sit here with you for 15 minutes.”

Explanation:
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.

Question 11.
After a few minutes of conversation, a client who is depressed wearily asks the nurse, “Why pick me to talk to? Go talk to someone else.” Which reply by the nurse is best?
(a) “I’m assigned to care for you today, if you’ll let me.”
(b) “You have a lot of potential, and I’d like to help you.”
(c) “I’ll talk to someone else later.”
(d)  “I’m interested in you and want to help you.”
Answer:
(d)  “I’m interested in you and want to help you.”

Explanation:
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.

Question 12.    
A client of Hispanic ethnicity has recently immigrated to this country and has been admitted for depression. The nurse documents that the client has poor eye contact during the medication teaching session. What is the most likely reason for the client’s behavior?
(a) The client does not like health care providers in this country.
(b) The client is demonstrating respect for the nurse.
(c) The client needs an assessment for suicide risk.
(d)  The client is experiencing psychosis with the depression.
Answer:
(b) The client is demonstrating respect for the nurse.

Explanation:
Persons of Latino/Hispanic ethnicity have traditionally been taught to avoid eye contact with those in authority as a sign of respect. Poor eye contact is not a consistent sign of suicidal or psychotic thoughts, which would be assessed through interview techniques. Other nonverbal cues such as tension or avoidance would indicate a dislike for the care provider.

Question 13.    
The health care provider prescribes fluoxetine orally every morning for a 72-year-old client with depression. Which transient adverse effect of this drug requires immediate action by the nurse?
(a) nausea
(b) dizziness
(c) sedation
(d)  dry mouth
Answer:
(b) dizziness

Explanation:
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.

Question 14.    
Which statement by a client taking trazodone as prescribed by the health care provider indicates to the nurse that further teaching about the medica¬tion is needed?
(a) “I’ll continue to take my medication after a light snack.”
(b) “Taking trazodone at night will help me to sleep.”
(c) “My depression will be gone in about 5 to 7 days.”
(d)  “I will not drink alcohol while taking trazodone.”
Answer:
(c) “My depression will be gone in about 5 to 7 days.”

Explanation:
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.

Question 15.    
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 with which statement?
(a) “Your mother will be given something for pain before the treatment.”
(b) “The health care provider (HCP) will make sure your mother does not suffer needlessly.”
(c) “Your mother will be asleep during the treatment and will not be in pain.”
(d)  “Your mother will be able to talk to us and tell us if she is in pain.”
Answer:
(c) “Your mother will be asleep during the treatment and will not be in pain.”

Explanation:
The nurse should explain that ECT is a safe treatment and that the client is given an ultrashortacting 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. Telling the daughter that the HCP 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.

Question 16.    
During a group session, a client who is depressed tells the group that he lost his job. Which response by the nurse is best?
(a) “It must have been very upsetting for you.”
(b) “Would you tell us about your job?”
(c) “You’ll find another job when you’re better.”
(d)  “You were probably too depressed to work.”
Answer:
(a) “It must have been very upsetting for you.”

Explanation:
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.

Question 17.    
A client who is very depressed exhibits psychomotor deficits, a flat affect, and apathy. The nurse observes the client to be in need of groom¬ing and hygiene. Which nursing action is most appropriate?
(a) explaining the importance of hygiene to the client
(b) asking the client if he is ready to shower
(c) waiting until the client’s family can participate in the client’s care
(d)  stating to the client that it is time for him to take a shower
Answer:
(d)  stating to the client that it is time for him to take a shower

Explanation:
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 selfcare. 

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.

Question 18.    
Which interventions should the nurse include in the plan of care to prepare a client for electrocon¬vulsive therapy (ECT)? Select all that apply.
(a) Maintain NPO status.
(b) Verify if consent is signed.
(c) Orient the client to place and time.
(d)  Remove dentures.
(e) Request the client to void.
(f) Assess client vital signs every 30 minutes.
 Answer:
 (a) Maintain NPO status.
(b) Verify if consent is signed.
(c) Orient the client to place and time.
(d)  Remove dentures.
(e) Request the client to void.

 Explanation:
(a), (b), (c), (d) (e) NPO status, a signed consent m removal of dentures, and preprocedure voiding are all preparations prior to a procedure involving anesthesia, such as ECT. Orientation and frequent assessment of vital signs occur after the procedure.
 
Question 19.    
Which comment indicates that a client understands the nurse’s teaching about sertraline?
(a) “Sertraline will probably cause me to gain weight.”
(b) “This medicine can cause delayed aculation.”
(c) “Dry mouth is a permanent side effect of sertraline.”
(d)  “I can take my medicine with St. John’s wort.”
Answer:
(a) “Sertraline will probably cause me to gain weight.”

Explanation:
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.

Question 20.    
The client with recurring depression will be discharged from the psychiatric unit. What instructions for the family are most important to include in the plan of care?
(a) Discourage visitors while the client is at home.
(b) Provide for a schedule of activities outside the home.
(c) Involve the client in usual at-home activities.
(d)  Encourage the client to sleep as much as possible.
Answer:
(c) Involve the client in usual at-home activities.

Explanation:
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

Question 21.
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 health care provider. The nurse understands this client legally committable based on which criterion?
(a) evidence of psychosis
(b) being gravely disabled
(c) risk of harm to self or others
(d)  diagnosis of mental illness
Answer:
(b) being gravely disabled

Explanation:
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 is gravely disabled because of his inability to care for himselfnamely, 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.

Question 22. 
The client states to the nurse, “I take citalo- pram 40 mg every day as my health care provider prescribed. I have also been taking St. John’s wort 750 mg daily for the past 2 weeks.” Which findings would indicate that the client is developing serotonin syndrome? Select all that apply.
(a) confusion
(b) restlessness
(c) constipation
(d)  diaphoresis
(e) ataxia
Answer:
(a) confusion
(b) restlessness
(c) constipation
(d)  diaphoresis

Explanation:
(a), (b), (c), (d) 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.

Question 23.    
Which food should the nurse tell the client to avoid while taking phenelzine?
(a) roasted chicken
(b) salami
(c) fresh fish
(d)  hamburger
Answer:
(b) salami

Explanation:
Phenelzine is a monoamine oxidase inhibitor (MAOIJ. 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. 

Question 24.    
A client is taking phenelzine 15 mg PO three times a day. The nurse is about to administer the next dose when the client tells the nurse about having a throbbing headache. Which action should the nurse do first?
(a) Give the client an analgesic prescribed PRN.
(b) Call the health care provider (HCP) to report the symptom.
(c) Administer the client’s next dose of phenelzine.
(d)  Obtain the client’s vital signs.
Answer:
(d)  Obtain the client’s vital signs.

Explanation:
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, the nurse would call the HCP Q 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.

Question 25.    
The nurse is caring for a severely depressed client. Which statement by the nurse is best when talking to the client on the patient care unit?
(a) “Everybody feels down once in a while.”
(b) “Things will get better.”
(c) “You’re wearing a new shirt today.”
(d)  “I like the shoes you wore yesterday.”
Answer:
(c) “You’re wearing a new shirt today.”

Explanation:
Pointing out facts of the present day draws the client into reality. By offering inane platitudes such as “everybody feels down once in a while,” or “things will get better” minimize the client’s feelings and may increase the feelings of worthlessness. Informing the client that the nurse liked something the client wore yesterday could make the client feel the nurse did not like other things he/she wore and requires the client to remember what that item was often difficult with severe depression.

Question 26.    
Which behavior if exhibited by a client with a depressive disorder should lead the nurse to determine that the client is ready for discharge?
(a) interactions with staff and peers 
(b) sleeping for 4 hours at a time 
(c) verbalization of feeling in control of self and situations
(d)  statements of dissatisfaction over not being able to perform at work
Answer:
(c) verbalization of feeling in control of self and situations

Explanation:
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 only 4 hours at a time 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.

Question 27.    
The client with major depression and suicidal ideation has been taking bupropion 100 mg PO 3 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 behavior?
(a) seizure activity
(b) suicide attempt
(c) visual disturbances
(d)  increased libido
Answer:
(b) suicide attempt

Explanation:
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 >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.

Question 28.    
Which outcome should the nurse include in the initial plan of care for a client who is exhibiting psychomotor deficits, withdrawal, minimal eye contact, and unresponsiveness to the nurse’s questions?
(a) The client will initiate interactions with peers.
(b) The client will participate in milieu activities.
(c) The client will discuss adaptive coping techniques.
(d) The client will interact with the nurse.
Answer:
(d) The client will interact with the nurse.

Explanation:
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.

Question 29.    
When preparing a teaching plan for a client about imipramine, which substance should the nurse tell the client to avoid while taking the medication?
(a) caffeinated coffee
(b) sunscreen
(c) alcohol
(d)  artificial tears
Answer:
(c) alcohol

Explanation:
Imipramine, a tricyclic antidepressant, in combination with alcohol will produce additive central 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.

Question 30.    
The client with depression who is taking imipramine states to the nurse, “My psychiatrist wants me to have an electrocardiogram (ECG) in 2 weeks, but my heart is fine.” Which response by the nurse is most appropriate?
(a) “It’s routine practice to have an ECG periodically because there is a slight chance that the drug may affect the heart.”
(b) “It’s probably a precautionary measure because I’m not aware that you have a cardiac condition.”
(c) “Try not to worry too much about this. Your health care provider (HCP) is just being very thorough in monitoring your condition.”
(d)  “You had an ECG before you were prescribed imipramine, and the procedure will be the same.”
Answer:
(a) “It’s routine practice to have an ECG periodically because there is a slight chance that the drug may affect the heart.”

Explanation:
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 is 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 HCP 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 proce¬dure will be the same does not answer the client’s question

Question 31.
When assessing a client who is receiving tricyclic antidepressant therapy, the nurse should be alert for which finding that could suggest the client is experiencing anticholinergic effects?
(a) tremors and cardiac arrhythmias 
(b) sedation and delirium
(c) respiratory depression and convulsions
(d)  urine retention and blurred vision
Answer:
(d)  urine retention and blurred vision

Explanation:
Anticholinergic effects, which result from blockage of the parasympathetic 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 older adult clients. Respiratory depression, convulsions, ataxia, agitation, stupor, and coma indicate tricyclic antidepressant toxicity.

Question 32.
The health care provider (HCP) prescribes mirtazapine 30 mg PO at bedtime for a client diag¬nosed with depression. Which nursing action is indicated?
(a) Give the medication as prescribed.
(b) Question the HCP’s prescription.
(c) Request to give the medication in the morning.
(d)  Give the medication in three divided doses.
Answer:
(a) Give the medication as prescribed.

Explanation:
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 HCP’s Q 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.

Question 33.    
When the nurse is developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include?
(a) pharmacokinetics of the medication
(b) current research related to the medication
(c) management of common adverse effects 
(d) dosage regulation and adjustment
Answer:
(c) management of common adverse effects 

Explanation:
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 HCP not the client, is the person in charge of this aspect.

Question 34.    
The client diagnosed with severe major depression has been taking escitalopram 10 mg daily for the past 2 weeks. Which parameter should the nurse monitor most closely at this time?
(a) suicidal ideation
(b) sleep H 
(c) appetite
(d) energy level
Answer:
(a) suicidal ideation

Explanation:
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.

Question 35.    
A client taking paroxetine 40 mg PO every morning tells the nurse that her mouth “feels like cotton.” Which statement by the client necessitates further assessment by the nurse?
(a) “I’m sucking on ice chips.”
(b) “I’m using sugarless gum.”
(c) “I’m sucking on sugarless candy.”
(d) “I’m drinking 12 glasses of water every day.”
Answer:
(d) “I’m drinking 12 glasses of water every day.”

Explanation:
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.

Question 36.    
The client with a depressive disorder has been consistent with taking 12.5 mg of paroxetine extended release daily. The nurse judges the client to be benefiting from this drug therapy when the client demonstrates which behaviors? Select all that apply.
(a) takes 2-hour evening naps daily
(b) completes homework assignments
(c) decreases pacing
(d)  increases somatization
(e) verbalizes feelings
Answer:
(b) completes homework assignments
(c) decreases pacing
(e) verbalizes feelings

Explanation:
(b), (c), (e) 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.

Question 37.    
A client diagnosed with major depression has sleep and appetite disturbances and a flat affect and is withdrawn. The client has been taking fluvox- amine 50 mg twice daily for 5 days. Which client behavior is most important to report to the next shift?
(a) client’s flat affect
(b) client’s interacting with a visitor
(c) client sleeping from 2300 hours to 10600 hours 
(d) client spending the entire evening in her room
Answer:
(c) client sleeping from 2300 hours to 10600 hours 

Explanation:
The most important behavior to report to the next shift is that the client was able to sleep from 2300 to 0600. 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 withdrawn behavior and is important to report but not as important as the improvement in sleep.

Question 38.    
A client with a major depressive disorder comes to the mental health clinic for a follow-up visit. The client has been taking escitalopram for 3 months and tells the nurse that he is feeling “like my old self again.” Now the client 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?
(a) “After another 3 months of stability, it might be safe for you to go off the escitalopram.”
(b) “After two significant episodes, you’ll need to take an antidepressant indefinitely.”
(c) “Research indicates that individuals who have had two major depressive episodes have a 70% chance of having a third episode.”
(d) “It's likely that you can learn to manage your depression with a regular exercise regime and a healthy diet.”
Answer:
(c) “Research indicates that individuals who have had two major depressive episodes have a 70% chance of having a third episode.”

Explanation:
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. 

Question 39.
Which statement made by an adolescent who has just begun taking an antidepressant would indicate the need for further teaching?
(a) “Now that I’ve been taking my antidepressant for a week, I’m going to feel better about myself.”
(b) “A week ago when I started my antidepressant, I didn’t care about eating, but now I want to eat a bit more.”
(c) “After a week of taking my antidepressant, I can sleep a little better 6 hours or so each night.”
(d)  “Now that I’ve had a week of my antidepressant, it’s a little easier to get up in the morning.”
Answer:
(a) “Now that I’ve been taking my antidepressant for a week, I’m going to feel better about myself.”

Explanation:
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.

Question 40.    
The client is taking 50 mg of lamotrigine daily for bipolar disorder. The client shows the nurse a rash on his arm. What should the nurse do?
(a) Report the rash to the health care provider (HCP).
(b) Explain that the rash is a temporary adverse effect.
(c) Give the client an ice pack for his arm.
(d)  Question the client about recent sun exposure.
Answer:
(a) Report the rash to the health care provider (HCP).

Explanation:
The nurse should immediately report the rash to the HCP 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.

Question 41.    
In a predischarge program to educate clients with bipolar disorder and their family members, the nurse emphasizes that which symptom is the most significant indicator for the onset of relapse?
(a) a sense of pleasure and motivation for new endeavors
(b) decreased need for sleep and racing thoughts
(c) self-concern about increase in energy
(d)  leaving a good job to start a new business
Answer:
(b) decreased need for sleep and racing thoughts

Explanation:
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. Also, leaving a job to start a new business is not, in itself, a sign of impending illness.

Question 42.
Which statement by a client taking lithium most indicates a need for more teaching?
(a) “I don’t have to worry about my levels because my last level was normal.”
(b) “I’ve been getting a lot of good exercise playing on a local soccer team.”
(c) “I’m trying hard to watch my diet and eat healthy.”
(d)  “I’ve learned to take my lithium even when I have the stomach flu.”
Answer:
(d)  “I’ve learned to take my lithium even when I have the stomach flu.”

Explanation:
The therapeutic serum level for lithium ranges from 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L), but levels do fluctuate with fluid intake and output. 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.

Question 43.
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 disorder and has been well managed on divalproex for at least 3 years. What is the most essential counsel for the nurse to give her?
(a) “Schedule an appointment for a complete gynecological exam if you haven't had one in the past year.”
(b) “Pay careful attention to eating healthy from this point on in order to maximize the health of both mother and baby.”
(c) “Check with your health care provider as divalproex carries an increased risk for birth defects.”
(d) “Learning to reduce stress now is important to reduce your chances of developing postpartum depression.”
Answer:
(c) “Check with your health care provider as divalproex carries an increased risk for birth defects.”

Explanation:
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 divalproex 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.

Question 44.    
A health care provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid?
(a) Follow-up blood tests are necessary while on this medication.
(b) The extended-release tablet can be crushed if necessary for ease of swallowing.
(c) Tachycardia and upset stomach are common side effects.
(d)  Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning.
Answer:
(a) Follow-up blood tests are necessary while on this medication.

Explanation:
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. Nausea and tachycardia are not common side effects of valproic acid.

Question 45.    
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 new medication may have contributed to the development of his manic state?
Medication Record Amitriptyline 50 mg PO daily at bedtime Prednisone 20 mg PO daily Buspirone HCI 5 mg PO three times a day Gabapentin 300 mg PO three times a day.
(a) amitriptyline
(b) prednisone
(c) buspirone
(d) gabapentin
Answer:
(b) prednisone

Explanation:
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.

Question 46.    
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 health care provider.
The client states, “I don’t need that stuff.” Which response by the nurse is best?
(a) “You can’t refuse to take this medication.”
(b) “If you don’t take it orally, I’ll give you a shot.”
(c) “The medication will help you feel calmer.”
(d)  “I’ll get you some written information about the medication.”
Answer:
(c) “The medication will help you feel calmer.”

Explanation:
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. The client was a voluntary admission and has the right to refuse any medication. Giving the medication as an injection against the client’s consent constitutes battery.
 
Question 47.    
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 statement by the nurse should benefit the client?
(a) “She won’t want to be around you with that kind of talk.”
(b) “Telling sexual jokes and touching others is not permitted here.”
(c) “You need to be careful about what you say to other people.”
(d)  “I think a time-out in your room would be appropriate now.”
Answer:
(b) “Telling sexual jokes and touching others is not permitted here.”

Explanation:
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.

Question 48. 
The nurse is preparing to administer a controlled substance to a client who was admitted to an inpatient unit after being injured during a manic episode. The single-dose vial contains more than is needed for the prescribed dose. Which nursing action is appropriate?
(a) Document wasting of the excess medication with a second witness.
(b) Document the excess and return excess medication to the pharmacy.
(c) Document the excess and return to the excess medication drawer for future use.
(d)  Document the prescribed dose and add the excess to a second vial for future use.
Answer:
(a) Document wasting of the excess medication with a second witness.

Explanation:
Wasting of all controlled substances requires an independent witness and documentation; at least one, but preferably both, of the witnesses should be licensed. For single-dose vials, the excess is not returned to the pharmacy or saved for a future dose of medication. Adding the excess to a second vial would necessitate breaking the seal on the second vial, increasing the volume in the vial and adding to the risk of controlled substance discrepancies.

Question 49.    
The client with mania is irritable and insulting to an unlicensed assistive personnel (UAP). The UAP states, “I can’t believe this client is so rude. Shouldn’t he be overly happy?” Which response by the nurse should help the UAP understand the client’s behavior?
(a) “It’s our responsibility to listen to him even though we might not like what he’s saying.”
(b) “We must reprimand him for doing that because there’s no reason for him to behave like that.”
(c) “I’ll go and speak to him about his behavior and make sure he understands that he needs to control what he’s saying.”
(d)  “I know it’s difficult, but being irritable is a symptom of the client’s mania.”
Answer:
(d)  “I know it’s difficult, but being irritable is a symptom of the client’s mania.”

Explanation:
The nurse should help the unlicensed assistive personnel (UAP) 21 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 is our responsibility to listen to him even though we might not like what he is saying” does not help the UAP 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.

Question 50. 
Which milieu activity should the nurse recommend to a client with acute mania? Select all that apply.
(a) scheduled rest periods
(b) relaxation exercises
(c) listening to soft music
(d)  watching television
(e) taking a walk
Answer:
(a) scheduled rest periods
(b) relaxation exercises
(c) listening to soft music
(e) taking a walk

Explanation:
(a), (b), (c), (e) 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. Walking 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.

Question 51.    
A nurse is assessing a client with a history of mania 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?
(a) “Are you thinking about hurting yourself?”
(b) “If you stop your medication, your behavior will quickly spiral out of control.”
(c) “I believe you were hospitalized the last time you stopped your medication.”
(d)  “Why don’t you cut your medication dosage in half for a while and see how you respond?”
Answer:
(c) “I believe you were hospitalized the last time you stopped your medication.”

Explanation:
Reminding the client of past consequences of stopping the medication may help her realize the risks of stopping the medication again. While increases in energy may precipitate suicide attempts, the priority here is to reinforce the need for maintenance medications. 

Encouraging the client to reduce her medication dose reinforces 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. Saying she will “spiral out of control” if she stops her medi-cation is not as specific as identifying the need for hospitalization.

Question 52.    
The client with acute mania is prescribed 600 mg of lithium PO three times per day. The health care provider (HCP) also prescribes 5 mg of haloperidol PO at bedtime. Which action should the nurse take?
(a) Administer the medication as prescribed.
(b) Question the HCP about the prescription.
(c) Administer the haloperidol but not the lithium.
(d)  Consult with the nursing supervisor before administering the medications.
Answer:
(a) Administer the medication as prescribed.

Explanation:
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. Haloperidol is usually discontinued when the lithium starts to take effect. There is no need to contact the HCP or supervisor as the prescription is appropriate. 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 the mental status examination (pleasant and cooperative, irritable, and guarded).

Question 53.    
The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, “I am the Queen of England. Bow before me.” The nurse interprets this statement as important to document as which area of the mental status examination?
(a) psychomotor behavior
(b) mood and affect
(c) attitude toward the nurse
(d) thought content
Answer:
(d)  thought content

Explanation:
The client’s statement “I am the Queen of England. Bow before me” is an example of a grandiose 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 

Question 54.
The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. What should the nurse do?
(a) Call the health care provider (HCP) for a prescription for lorazepam as needed.
(b) Place the client in seclusion and call the HCP for a prescription for the seclusion.
(c) Ignore the client's behavior in order not to give the client too much attention.
(d)  Ask the client to come to a quiet area to talk to the nurse individually.
Answer:
(d)  Ask the client to come to a quiet area to talk to the nurse individually.

Explanation:
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. Lorazepam can be used, but benzodiazepines can lead to dependence and should not be used before other measures have been tried.

Question 55.    
A client with acute mania exhibits euphoria, pressured speech, and flight of ideas. The client has been talking to the nurse nonstop for 5 minutes, and lunch has arrived on the unit. What should the nurse do next?
(a) Excuse oneself while telling the client to come to the dining room for lunch.
(b) Tell the client he needs to stop talking because it is time to eat lunch.
(c) Do not interrupt the client, but wait for him to finish talking.
(d)  Walk away, and approach the client in a few minutes before the food gets cold.
Answer:
(a) Excuse oneself while telling the client to come to the dining room for lunch.

Explanation:
The nurse would request to be excused, showing respect and regard for the client, while tell¬ing 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 is lunchtime is disrespect¬ful 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.

Question 56.    
A client with acute mania brings six suitcases and three shopping bags of personal belongings on admission to the unit. When informed that some of the suitcases and bags need to be returned home because of a lack of storage space, the client begins to use profanity against the nurse. Which response by the nurse is most therapeutic?
(a) “You’re acting inappropriately.”
(b) “I won’t tolerate your talking to me like that.”
(c) “Swearing and profanity are unacceptable here.”
(d)  “We don’t want to put you in seclusion yet.”
Answer:
(c) “Swearing and profanity are unacceptable here.”

Explanation:
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.

Question 57.    
The husband of a client who is experienc¬ing acute mania and is swearing and using profanity apologizes to the nurse for his wife’s behavior. Which reply by the nurse is most therapeutic?
(a) “This must be difficult for you.”
(b) “It’s okay. We’ve heard worse.”
(c) “How long has she been like this?”
(d) “She needs some medication.”
Answer:
(a) “This must be difficult for you.”

Explanation:
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.

Question 58.    
The nurse is caring for a client with acute mania who is euphoric and flirtatious. The nurse overhears the client describing a sexual exploit with a group of clients seated at a table. What immediate action should the nurse take?
(a) Continue walking down the hall, ignoring the conversation.
(b) Speak to the client later in private while saying nothing at this time.
(c) Tell the client others may not want to hear about sex, and invite him to play a game of ping-pong.
(d)  Inform the client that if he continues to talk about sex, no one will want to be around him.
Answer:
(c) Tell the client others may not want to hear about sex, and invite him to play a game of ping-pong.

Explanation:
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.

Question 59.    
The client with acute mania states to the nurse, “I am the prince of peace and can save the world. Those against me will find me and take me to another world. They will come. I know it.” The client is beginning to scan the room and starts to repeat his delusion. Which response by the nurse is most therapeutic?
(a) “Describe the people who will come.”
(b) “The staff and I will protect you.”
(c) “You’re not the prince of peace. Your name is Joe.”
(d)  “Let us walk around the unit for a while.”
Answer:
(d)  “Let us walk around the unit for a while.”

Explanation:
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.

Question 60.    
A client with bipolar disorder, manic phase, is scheduled for a chest X-ray. What should the nurse do before taking the client to the radiology department?
(a) Give a thorough explanation of the procedure.
(b) Explain the procedure in simple terms.
(c) Call security to be on standby for possible problems.
(d)  Cancel the appointment until the client can go unescorted.
Answer:
(b) Explain the procedure in simple terms.

Explanation:
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.

Question 61.
The client with bipolar disorder, manic phase, appears at the nurse’s station wearing a transparent shirt, miniskirt, high heels, 10 bracelets, and 8 necklaces. Her makeup is overdone, and she is not wearing underwear. What should the nurse do?
(a) Tell the client to dress appropriately while out of her room.
(b) Ask the client to put on hospital pajamas until she can dress appropriately.
(c) Instruct the client to go to her room and change clothes.
(d)  Escort the client to her room, and assist with choosing appropriate attire.
Answer:
(d)  Escort the client to her room, and assist with choosing appropriate attire.

Explanation:
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.

Question 62.
A client diagnosed with bipolar disorder and experiencing acute mania states to the nurse, “Where is my son? I love Lucy. Rain, rain go away. Dogs eat dirt.” Another client approaches the nurse and says, “Man, is he ever nuts! He is driving me crazy with all his weird talk.” Which response by the nurse to the second client is most appropriate?
(a) “I agree. He’s a little hard to take sometimes.”
(b) “Just walk away and leave him alone. There’s nothing else you can do.”
(c) “I realize his behavior bothers you, but he can’t control it right now.”
(d)  “I’ll give him some medication so he won’t bother you.”
Answer:
(c) “I realize his behavior bothers you, but he can’t control it right now.”

Explanation:
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 upset client gain empathy for his peer and only temporarily deals with the problem.

Question 63.
The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client’s plan of care?
(a) leading a group activity
(b) watching television
(c) reading the newspaper
(d)  cleaning the dayroom tables
Answer:
(d)  cleaning the dayroom tables

Explanation:
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 may cause 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.

Question 64. 
A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client’s daily assessment, the nurse should be especially alert for which finding?
(a) exhaustion
(b) vertigo
(c) gastritis
(d) bradycardia
Answer:
(a) exhaustion

Explanation:
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.

Question 65. 
The wife of a client with bipolar disorder, manic phase, states to the nurse, “He’s acting so crazy. What did he do to get this way?” The nurse bases the response on which understanding of this disorder?
(a) It is caused by underlying psychological difficulties.
(b) It is caused by disturbed family dynamics in the client’s early life.
(c) It is the result of an imbalance of chemicals in the brain.
(d)  It is the result of a genetic inheritance from someone in the family.
Answer:
(c) It is the result of an imbalance of chemicals in the brain.

Explanation:
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.

Question 66. 
A client diagnosed with bipolar disorder asks the nurse why it is necessary to have a serum lithium level drawn every 3 to 4 months. The nurse’s response should be based on which factor?
(a) to monitor compliance with the medication
(b) to prevent toxicity related to the drug’s therapeutic range
(c) to monitor the client’s white blood cell count
(d)  to comply with governmental safety requirements
Answer:
(b) to prevent toxicity related to the drug’s therapeutic range

Explanation:
The serum lithium level has nothing to do with the client’s white blood cell count, and there are no governmental safety regulations 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.

Question 67.    
The health care provider (HCP) prescribes a serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At what time should the nurse plan to have the blood specimen obtained?
(a) before bedtime
(b) after lunch
(c) before breakfast
(d) during the afternoon
Answer:
(c) before breakfast

Explanation:
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.

Question 68.    
A client will be discharged on lithium carbonate 600 mg three times daily. When teaching the client and his family about lithium therapy, the nurse determines that teaching has been effective if the client and family state that they will notify the prescribing health care provider (HCP) immediately with which symptoms? Select all that apply.
(a) nausea
(b) muscle weakness
(c) vertigo
(d)  fine hand tremor
(e) vomiting
(f) anorexia
Answer:
(b) muscle weakness
(c) vertigo
(e) vomiting

Explanation:
(b), (c), (e) Serious side effects that may indicate lithium toxicity include muscle weakness, vertigo, vomiting, extreme hand tremor, and sedation. The prescribing HCP Q 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.

Question 69.    
After the nurse teaches a client with bipolar disorder about lithium therapy, which client statement indicates the need for additional teaching?
(a) “It’s important to keep using a regular amount of salt in my diet.”
(b) “It’s okay to double my next dose of lithium if I forget a dose.”
(c) “I should drink about 8 to 10 8-oz (240 to 300rmL) glasses of water each day.”
(d)  “I need to take my medicine at the same time each day.”
Answer:
(b) “It’s okay to double my next dose of lithium if I forget a dose.”

Explanation:
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 more rapidly. A decrease in salt intake leads to increased plasma lithium levels. The client needs to drink 8 to 10 8-oz (240 to 300 mL) glasses 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 toxic¬ity. Lithium must be taken on a regular basis at the same time each day to ensure maximum therapeutic effect.

Question 70.    
A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol PO at bedtime. Which action should the nurse take?
(a) Refuse to give the medications as prescribed. 
(b) Give the lithium only.
(c) Request a decreased dosage of lithium.
(d)  Give the medications as prescribed. 
Answer:
(d)  Give the medications as prescribed. 

Explanation:
Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam. Antipsychotic agents, such as haloperidol, are prescribed to produce a neuroleptic effect until the lithium 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. 

Question 71. 
During morning community meeting, a client with bipolar disorder, manic phase, interrupts others to the point where no one can finish their statements. What should the nurse tell the client?
(a) “Please stop interrupting others. You can speak when it’s your turn.’’
(b) “Stop talking. It’s time for you to leave the meeting.”
(c) “If you can’t control yourself, we’ll have to take action.”
(d)  “Please behave like an adult. Your behavior is childish."
Answer:
(a) “Please stop interrupting others. You can speak when it’s your turn.’’

Explanation:
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 is 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.

Question 72. 
The client with bipolar disorder, manic phase, has a subtherapeutic valproic acid level. Which client behaviors should the nurse judge to be due to this level of valproic acid? Select all that apply.
(a) irritability
(b) grandiosity
(c) anhedonia
(d)  hypersomnia
(e) flight of ideas
Answer:
(a) irritability
(b) grandiosity
(e) flight of ideas

Explanation:
(a), (b), (e)  The therapeutic level of valproic acid is 50 to 100 mg/mL (347 to 693 mmol/L). Clients with sub therapeutic valproic acid levels most likely 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.

Question 73.
The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next?
(a) Administer the prescribed dose of carbamazepine.
(b) Give the client acetaminophen as prescribed PRN.
(c) Report the symptoms to the health care provider (HCP) in the morning.
(d)  Call the HCP immediately to report changes.
Answer:
(d)  Call the HCP immediately to report changes.

Explanation:
The nurse should call the HCP CO 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.

Question 74. 
A client’s wife states, “I don’t know what to do sometimes. It’s so hard having a husband with a mental illness like bipolar disorder.” After the nurse talks with the client’s wife about her feelings and difficulties, which action is most appropriate?
(a) Suggest that the wife see her health care provider (HCP).
(b) Give the wife information about a support group.
(c) Recommend that the wife talk with her close friend.
(d)  Have the wife share her feelings with her husband.
Answer:
(b) Give the wife information about a support group.

Explanation:
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 an HCP 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 sup¬port 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.

Question 75.
The client with bipolar disorder is approaching discharge after being hospitalized with her first episode of acute mania. The client’s husband asks the nurse what he can do to help her. What recommendation for the husband should the nurse anticipate including in the teaching plan?
(a) Help the client to be free from worry and anxiety.
(b) Communicate openly and offer support.
(c) Relieve the client of all responsibilities.
(d)  Remind the client to control her symptoms.
Answer:
(b) Communicate openly and offer support.

Explanation:
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.

 Question 76.    
 A client experiencing a manic episode has been talking loudly, pacing the unit and trying to draw other clients into debates about the value of self-determination. Arrange in order the steps a nurse should take to help calm this client. All options must be used.
(a) Use oral medication to decrease anxiety and increase appropriate social interaction.
(b) Talk with the client about the anxiety and stress the client is feeling.
(c) Take client to a quite aarea. Such as his or her room to decrease stimuli.
(d) Teach the client coping strategies to deal with stressors.
 Answer:
 (c) Take client to a quite aarea. Such as his or her room to decrease stimuli.
 (a) Use oral medication to decrease anxiety and increase appropriate social interaction.
(b) Talk with the client about the anxiety and stress the client is feeling.
(d) Teach the client coping strategies to deal with stressors.

 Explanation:
(c), (a), (b), (d) None of the other interventions will be successful unless the stimuli that fuel the client’s mania are removed 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.

Question 77.    
The client with bipolar disorder, manic phase, states to the nurse, “You’re looking good. I’m taking you out to dinner.” What reply by the nurse is most therapeutic?
(a) “I don’t want to go out to dinner.”
(b) “I can’t go out to dinner with you.”
(c) “It doesn’t matter how I look; the answer is no.”
(d)  “I’m Chris Smith, a nurse working on this unit.”
Answer:
(d)  “I’m Chris Smith, a nurse working on this unit.”

Explanation:
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 does not want to or cannot 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.”

Question 78.    
The nurse administers an antipsychotic drug to a client with acute mania. The client still refuses to lie down on her bed, pushes other clients in the hallways, and screams threatening remarks to the staff. What should the nurse do next?
(a) Follow the client and ask her to calm down.
(b) Tell the client to lie down on the sofa in the community room.
(c) Seclude the client and use restraints if necessary.
(d)  Tell the staff to ignore the client’s remarks. 
Answer:
(c) Seclude the client and use restraints if necessary.

Explanation:
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.

Question 79. 
As the nurse is turning off the television, a client with bipolar disorder, manic phase, says, “I want the television on so I can watch the late show. I’m not tired, and you can’t tell me what to do. I want it on!” What should the nurse tell the client?
(a) “I’ll let you watch television just this once, but you have to turn the sound off.”
(b) “I’ll turn the television off when you get sleepy. Don’t ask me to do this again.”
(c) “Television hours are from 1900 hours to 2200 hours. It’s 2200, and the television goes off so everyone can sleep.”
(d)  “The television goes off at 2200 hours. I’ve been telling you this for the past three evenings.”
Answer:
(c) “Television hours are from 1900 hours to 2200 hours. It’s 2200, and the television goes off so everyone can sleep.”

Explanation:
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 1900 hours to 2200 hours. It’s 2200, 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” 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 2200 hours; I’ve been telling you this for the past three evenings,” is inappropriate because it is authoritative and demeaning to the client.

Question 80. 
Which strategies would be helpful in preventing suicide for clients about to be discharged from a psychiatric inpatient unit? Select all that apply.
(a) At discharge, give all depressed clients a card containing the crisis phone line number for their area.
(b) Have all clients who have expressed suicidal ideation just prior to or during hospitalization make a written personal suicide prevention plan.
(c) Require that all clients who have had previous suicidal ideation, plans, or attempts refill all prescriptions every 2 weeks rather than monthly.
(d)  Educate family and friends of previously suicidal clients in ways to help clients remain safe after discharge.
(e) Suggest that family and friends of previously suicidal clients know the client’s whereabouts at all times.
Answer:
(a) At discharge, give all depressed clients a card containing the crisis phone line number for their area.
(b) Have all clients who have expressed suicidal ideation just prior to or during hospitalization make a written personal suicide prevention plan.
(d)  Educate family and friends of previously suicidal clients in ways to help clients remain safe after discharge.

Explanation:
(a), (b), (d) 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.

Question 81.
The nurse manager in the emergency department (ED) conducts an in-service for the nursing staff about screening clients for suicide. One of the nurses states, “Questioning adolescents about suicide will only increase their thinking about selfharm, and they wouldn’t admit it to me anyhow.” How should the nurse manager respond?
(a) “You could be correct. Let’s assess only adults because they’ll be more honest.”
(b) “We’ll limit the assessment to adolescents with psychiatric diagnoses.”
(c) “It’s a myth that talking about suicide leads to suicide attempts. Adolescents will disclose suicidal thoughts when asked directly.”
(d)  “If you think the adolescent isn’t telling you the truth, you can question the parents.”
Answer:
(c) “It’s a myth that talking about suicide leads to suicide attempts. Adolescents will disclose suicidal thoughts when asked directly.”

Explanation:
It is important to assess clients in the ED for suicide risk so that those with the potential can receive help prior to discharge. Many visitors to the ED have no other source for health care. It is a myth that talking about suicide will cause young 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.

Question 82.
When assessing a client for suicidal risk, which method of suicide should the nurse identify as most lethal?
(a) overdosing on aspirin
(b) use of a gun to the stomach
(c) jumping off an 8-foot bridge
(d)  slashing both wrists
Answer:
(b) use of a gun to the stomach

Explanation:
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 poi-soning, 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. Jumping of an 8-foot bridge may cause injury, but it is not likely to be lethal.

Question 83.    
The nurse manager overhears two staff members talking in the snack room. One of the staff members states, “Her superficial cuts are just a means of getting our attention. She never should have been admitted. I hope she’s out of here soon.” Which response by the nurse manager is most appropriate?
(a) “It’s our job to help her no matter how we feel about her or what she did. She’ll be dis¬charged soon."
(b) “I won't tolerate that kind of discussion from my staff. Now, it’s time for you to go back to work.”
(c) “I know it’s hard to understand, but we need to do the best we can even though she’ll be back.”
(d)  “No matter what the intent, all suicidal behavior is serious and deserves our serious consideration.”
Answer:
(d)  “No matter what the intent, all suicidal behavior is serious and deserves our serious consideration.”

Explanation:
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 dis-charged 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’s 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 knowl-edge. As such, this statement is inappropriate.

Question 84.    
The history of a female client who has just been admitted to the unit and is very depressed reveals a weight loss of 10 lb (4.5 kg) in 2 weeks, sleeping 3 hours a night, and poor hygiene. The client states, “I’m no good to anyone. Everyone would be better off without me.” Which question should the nurse ask first?
(a) “What do you mean?”
(b) “Are you thinking about hurting yourself?”
(c) “Does your family not care about you?”
(d)  “What happened to make you think that?”
Answer:
(b) “Are you thinking about hurting yourself?”

Explanation:
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 “Does your family not 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.

Question 85.
When developing the plan of care for a client with suicidal ideation, the nurse should address which priority issue?
(a) self-esteem
(b) sleep
(c) stress
(d)  safety
Answer:
(d)  safety

Explanation:
For the client with suicidal ideation, client safety is the priority. The nurse protects the client from self-harm or self-destruction. Although selfesteem, sleep, and stress are common areas that require intervention for a client with suicidal ideation, ensuring the client’s safety is the most immediate and serious concern.

Question 86.    
Which question should the nurse ask to best determine the seriousness of a client’s suicidal ideation?
(a) “How are you planning on harming yourself?”
(b) “Have you made out a will?”
(c) “Does your family know you’re here?”
(d)  “How long have you been thinking about harming yourself?”
Answer:
(a) “How are you planning on harming yourself?”

Explanation:
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 or her 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 or she 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.

Question 87.    
The unlicensed assistive personnel (UAP) states to the nurse, “My client talks about how awful and useless she is. Sometimes, she sounds angry for no reason. I’m tired of listening to her.” Which response by the nurse is most appropriate?
(a) “I’ll switch your assignment to someone who is less depressed and less tiring.”
(b) “It’s important for you to listen to her because she needs to verbalize how she’s feeling.”
(c) “Don’t worry about it. I know you haven’t done anything to make her angry.”
(d)  “Clients with depression are hard to deal with, but don’t take what they say seriously.”
Answer:
(b) “It’s important for you to listen to her because she needs to verbalize how she’s feeling.”

Explanation:
The nurse’s best response is to teach the UAP 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 UAP that the assignment will be switched or not to worry about it is not appropriate because it does not teach the UAP about the client’s illness and appropriate client care. The statement “Clients who are depressed are hard to deal with, but do not take what they say seriously” does not help the staff member understand why listening is important and may jeopardize the client’s safety.

Question 88.    
A client who was recently discharged from the psychiatric unit telephones the unit to speak to the nurse. The client states that she took her chil¬dren to the neighbors’ house and has turned on the gas to kill herself. Which action should the nurse take next?
(a) Refer the caller to a 24-hour suicide hotline.
(b) Tell the caller that another nurse will telephone the police.
(c) Ask the caller whether she telephoned her health care provider (HCP).
(d)  Instruct the caller to telephone her family for help.
Answer:
(b) Tell the caller that another nurse will telephone the police.

Explanation:
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 HCP is not appropriate. The nurse is responsible for notifying the HCP.

Question 89.    
A client walks into the clinic and tells the nurse she wants to die because her boyfriend broke up with her. The client states, “I’ll show him. He’ll be sorry.” The nurse notes which underlying theme and method to deal with the client?
(a) Sadness ask the client to reveal how long she has felt this way.
(b) Escape ask the client to indicate what she wants to escape.
(c) Loneliness ask the client to state who she believes to be her friends.
(d)  Retaliation ask the client about her specific plans to harm herself and/or her boyfriend.
Answer:
(d)  Retaliation ask the client about her specific plans to harm herself and/or her boyfriend.

Explanation:
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.

Question 90.    
The client has been hospitalized for major depression and suicidal ideation. Which statement indicates to the nurse that the client is improving?
(a) “I couldn’t kill myself because I don’t want to go to hell.”
(b) “I don’t think about killing myself as much as I used to.”
(c) “I’m of no use to anyone anymore.”
(d)  “I know my kids don’t need me anymore since they’re grown.”
Answer:
(b) “I don’t think about killing myself as much as I used to.”

Explanation:
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 grown” indicate that the client feels worthless and may be experiencing suicidal ideation.
 
Question 91.
The client states to the nurse at the outpatient clinic, “I don’t feel ready to go back to work. It’s only been a week since I left the hospital.” Assessment reveals a flat affect, disheveled appearance, poor posture, and minimal eye contact during interaction. The nurse asks the client whether he is thinking about harming himself. The client tells the nurse he has a loaded revolver at home and will probably use it. What should the nurse do next?
(a) Tell the client to go and remove the gun from his home.
(b) Ask the client to call the nurse every hour when he gets home.
(c) Ask the client to promise not to harm himself.
(d)  Initiate plans for hospitalization immediately.
Answer:
(d)  Initiate plans for hospitalization immediately.

Explanation:
Based on the client’s statement, the nurse must initiate plans for hospitalization immediately because the client has suicidal ideation with a definite plan, lethal method, and immediate access to the method. Telling the client to remove the gun, call the nurse, or promise not to hurt himself does not sufficiently reduce the risk of suicide

Question 92.
The widow of a client who successfully completed suicide tearfully says, “I feel guilty because I’m so angry at him for killing himself. It must have been what he wanted.” After assisting the widow with dealing with her feelings, which intervention is most helpful?
(a) Referring her to a group for survivors of suicide.
(b) Encouraging her to receive counseling from a chaplain.
(c) Providing her with the local suicide hotline number.
(d)  Suggesting she receive individual therapy by the nurse.
Answer:
(a) Referring her to a group for survivors of suicide.

Explanation:
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 experi-encing 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.

Question 93.
The husband of a client to be discharged from the hospital after an episode of major depres¬sion and a suicide attempt asks, “What can I do if she tries to kill herself again?” Which response is most appropriate?
(a) “Don’t worry. She’ll be okay as long as she takes her medication.”
(b) “She told me she wants to live, so I don’t think she will try again.”
(c) “Let’s talk about some behavioral clues and resources that can help.”
(d)  “Tell her about your concern, and just take care of her.”
Answer:
(c) “Let’s talk about some behavioral clues and resources that can help.”

Explanation:
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.

Question 94. 
A client with depression is exhibiting a brighter affect and an ability to attend to hygiene and grooming tasks and is beginning to participate in group activities. The nurse asks the client to identify three of her strengths. After much hesitation and thinking, the client can state she is usually a nice person, a good cook, and a hard worker. What should the nurse do next?
(a) Ask the client to identify additional three strengths.
(b) Volunteer the client to lead the cooking group later in the day.
(c) Educate the client about the importance of medication.
(d)  Reinforce the client for identifying and sharing her strengths.
Answer:
(d)  Reinforce the client for identifying and sharing her strengths.

Explanation:
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.

Question 95.
The friend of a client with depression and suicidal ideation asks the nurse, “How should I act around her?” Which response by the nurse is best?
(a) “Try to cheer her up.”
(b) “Be caring and genuine.”
(c) “Control your expressions.”
(d)  “Avoid asking how she’s feeling.”
Answer:
(b) “Be caring and genuine.”

Explanation:
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.

Question 96.    
The nurse is completing an assessment in the outpatient clinic on a client with depression who has been talking about how “it would be better if he wasn’t here anymore.” What questions are important for the nurse to ask the client? Select all that apply.
(a) “Do you want to hurt yourself?”
(b) “How long do you think it would take you to feel different?”
(c) “Do you have a gun at your home?”
(d)  “How many of your medication, imipramine, tablets do you have at home?”
(e) “Do you live alone?”
Answer:
(a) “Do you want to hurt yourself?”
(c) “Do you have a gun at your home?”
(d)  “How many of your medication, imipramine, tablets do you have at home?”
(e) “Do you live alone?”

Explanation:
(a), (c), (d), (e)nThe question “Do you want to harm yourself?” is straightforward and asks the question regarding suicidal plans. A gun in the home as well as more than a week’s worth of imipramine are lethal suicidal methods. Living alone allows the client to carry out suicidal plans more easily than if the client lives with another person or persons. Asking how long it could take to feel different does not address the plan or the lethality of suicide.

Question 97.    
A client is brought to the psychiatric unit from the emergency department (ED) escorted by ED staff and a security officer. The client’s shoulder is bandaged, and his arm is in a sling because of a self-inflicted gunshot wound to his shoulder. Later, the client’s wife follows with a bag of her husband’s belongings. Which nursing action is most appropriate at this time?
(a) Tell the wife to take her husband’s things home because he is suicidal.
(b) Instruct the wife to unpack the bag and put her husband’s things in the dresser.
(c) Ask the wife whether the bag contains anything dangerous.
(d)  Inspect the bag and its contents in the presence of the client and his wife.
Answer:
(d)  Inspect the bag and its contents in the presence of the client and his wife.

Explanation:
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.

Question 98.    
A suicidal client is placed in the seclusion room and given lorazepam because she tried to harm herself by banging her head against the wall. After 10 minutes, the client starts to bang her head against the wall in the seclusion room. Which action should the nurse take next?
(a) Call hospital security for assistance.
(b) Place the client in restraints.
(c) Call the health care provider (HCP) for additional medication prescriptions.
(d)  Instruct a staff member to sit in the room with the client.
Answer:
(b) Place the client in restraints.

Explanation:
The nurse and staff should place the client in restraints to protect her from further self-harm. The client’s behavior is out of control and necessitates external controls for her safety. The health care team is trained to deal with this type of behaviors, so there is no reason to call hospital security at this time. Calling the HCP for additional medication prescriptions is not appropriate because the loraz- epam 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.

Question 99.    
A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, “The voices are telling me to hurt myself again.” Which question by the nurse is most important to ask?
(a) “When do you hear the voices?”
(b) “Are you going to hurt yourself?”
(c) “How long have you heard the voices?”
(d)  “Why are the voices starting again?”
Answer:
(b) “Are you going to hurt yourself?”

Explanation:
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.

Question 100.    
A 20-year-old client diagnosed with paranoid schizophrenia is recovering from his first psychotic break. Before discharge from the hospital, the client becomes depressed and states, “I don’t want this illness. I’m about to begin my junior year in college.” Which issue would be most important for the nurse to address at this time?
(a) disturbed thought process
(b) disturbed sensory perceptions
(c) communication problems
(d)  potential for medication noncompliance
Answer:
(d)  potential for medication noncompliance

Explanation:
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.

Question 101.
The nurse is teaching two unlicensed assistive personnel who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made?
(a) “I need to check the client precisely at 15-minute intervals.”
(b) “Documenting suicide checks is absolutely necessary.”
(c) “Clients on one-to-one suicide precautions can never be left alone.”
(d)  “All clients using razors must be supervised by staff.”
Answer:
(c) “Clients on one-to-one suicide precautions can never be left alone.”

Explanation:
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.

Question 102.
Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?
(a) keeping track of feelings in a journal
(b) engaging in physical activity 
(c) talking with the nurse
(d)  playing a card game with other clients
Answer:
(c) talking with the nurse

Explanation:
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, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.

Question 103.    
For the client receiving outpatient treatment for depression and suicidal ideation, what is the correct amount of imipramine to have at one time?
(a) a 30-day supply
(b) a 21-day supply
(c) a 14-day supply
(d) a 7-day supply 
Answer:
(d) a 7-day supply 

Explanation:
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-day 21-day 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.

Question 104.    
The client with recurrent depression and suicidal ideation tells the nurse, “I can’t afford this medicine anymore. I know I’ll be okay without it.” What should the nurse do next?
(a) Inform the health care provider (HCP) of the client’s statement.
(b) Ask the social worker to find financial assistance for the client.
(c) Schedule a follow-up appointment in 48 hours.
(d) Ask the client whether a family member could help.
Answer:
(b) Ask the social worker to find financial assistance for the client.

Explanation:
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 HCP is the person responsible for prescribing the client’s medication, routinely, the HCP is not involved in finding financial assistance for the client’s medication needs. The client needs the medication at the present time. Scheduling a follow-up appointment in 48 hours does not address the immediate concern. The client could stop the medication before being seen and could become severely depressed. 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.

Question 105.    
Which statement by the nurse reflects the best understanding about suicide in an individual with depression?
(a) “The more severe the depression, the greater the probability for suicidal behavior. ”
(b) “The person who talks about suicide is less likely to try it. ”
(c) “Every client with depression is potentially suicidal.”
(d)  “Suicide is less likely when the individual is receiving antidepressant therapy.”
Answer:
(c) “Every client with depression is potentially suicidal.”

Explanation:
Statistics do not apply when focusing 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 have talked 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.

Question 106.    
A couple informs the nurse that they have been having some “problems in the bedroom.” What is most appropriate response by the nurse?
(a) “I can refer you to a therapist.”
(b) “I need to obtain your admission history first.”
(c) “I’d like to hear your concerns.”
(d)  “Let me refer you to a marriage counselor.”
Answer:
(c) “I’d like to hear your concerns.”

Explanation:
Telling the couple that the nurse would like to hear about their concerns invites open communication. Telling the clients that admission history is needed first gives the client the impression that the issue is not important; the couple may not want to bring the subject up in the future. Referring the client to a therapist or marriage counselor is appropriate only after determining the nature of the problem

Question 107.    
A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that he has pedophilia. What should the nurse do?
(a) Be aware of personal opinions and views.
(b) Recognize that because the client is depressed, the client will not be able to discuss the pedophilia.
(c) Ensure that the client is never alone with other clients on the unit.
(d)  Refer the client to group therapy.
Answer:
(a) Be aware of personal opinions and views.

Explanation:
The nurse must be aware of personal opinions and views when caring for clients with psycho- sexual disorders. The care plan for the client will be developed to manage both the depression and the pedophilia. It is not necessary to restrict the client’s interactions with others on this adult mental health unit. The health care provider (HCP) Q will deter-mine the type of therapy that will be most appropriate for this client.

Question 108.    
A client and her partner come to the clinic stating they have been unable to have sexual intercourse. The female client states she has pain and her “vagina is too tight.” The client was raped at age 15 years of age. Which nursing problem is most appropriate for this client?
(a) dysfunctional grieving related to loss of selfesteem because of lack of sexual intimacy
(b) risk for trauma related to fear of vaginal penetration
(c) vaginismus related to vaginal constriction 
(d) sexual dysfunction related to sexual trauma
Answer:
(d) sexual dysfunction related to sexual trauma

Explanation:
Sexual dysfunction is the problem that is the most appropriate. Dysfunctional grieving because of lack of intimacy is not correct as the couple may have emotional intimacy. The trauma occurred when the female client was 15 years of age and thus is not an acute problem. Vaginismus is a medical diagnosis.
 
Question 109.    
A client with erectile disorder is taking sildenafil. What instructions should the nurse give the client?
(a) Take the medication 8 hours before having intercourse.
(b) Use nitroglycerin if chest pains occur during intercourse.
(c) Take up to three tablets within 24 hours.
(d)  Expect an erection that may last up to 4 hours.
Answer:
(d)  Expect an erection that may last up to 4 hours.

Explanation:
An expected outcome of taking sildenafil is an erection that can last up to 4 hours. The nurse instructs the client to take the medication 1 hour before having intercourse as an erection will occur within 1 hour and to take only one tablet in 24 hours. The nurse advises the client to avoid taking the drug if he takes nitrate therapy, such as nitroglycerin, to avoid unsafe decreases in blood pressure.

Question 110.    
The nurse is caring for a client with bipolar disorder who was recently admitted to an inpatient unit and is experiencing a manic episode. What is a priority nursing intervention for this client?
(a) Prescribe and administer all medications in a liquid form.
(b) Base permission for family visits on the client’s attendance at therapy groups.
(c) Closely monitor the client’s eating and sleeping habits.
(d)  Encourage the client to keep a journal about feelings and emotions.
Answer:
(c) Closely monitor the client’s eating and sleeping habits.

Explanation:
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.

Question 111.
Which reaction to learning about a diagnosis of being HIV positive would put the client at the greatest need of intervention by the nurse?
(a) a person who is angry, hostile, and alienated from the family
(b) a person who is obsessed with cleanliness and showers many times a day
(c) a person who is unable to make decisions and is helpless and tearful
(d)  a person who says, “I’ve found a solution for this mess”
Answer:
(d)  a person who says, “I’ve found a solution for this mess”

Explanation:
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

Question 112.
Which represents an ethical breach regarding the rights of clients in psychiatric care situations?
(a) The nurse discusses client’s care with out- of-town family members who the client has formally indicated are allowed to know about the client’s hospital care.
(b) The nurse discusses the client’s history and hospital course of treatment with a consulting health care provider [HCP],
(c) The nurse discusses with peers in the hospital cafeteria the progress of a well-known client being cared for at the hospital.
(d)  The nurse discusses the client’s care with the admission coordinator of a retirement home that the client plans to enter after discharge from the hospital.
Answer:
(c) The nurse discusses with peers in the hospital cafeteria the progress of a well-known client being cared for at the hospital.

Explanation:
The nurse communicates with consulting HCPs 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 or with team members in a public place without the client’s permission is a breach of ethics by the nurse.

Question 113.
A client diagnosed with schizophrenia for the last 2 years tells the nurse who has brought the morning medications, “That’s not my pill! My pill is blue, not green.” What should the nurse tell the client?
(a) “Go ahead and take it. You can trust me. I’m watching out for your safety and well- being.”
(b) “I know I took the correct medication out of the dispenser. Don’t you trust me?”
(c) “Don’t worry; your medication is generic, and sometimes the manufacturers change the color of the pills without letting us know.”
(d)  “I’ll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color.”
Answer:
(d)  “I’ll go back and check the drawer as well as telephone the pharmacy to check about any possible changes in the medication color.”

Explanation:
It is important for the nurse to listen to the client and respect his or her knowledge about the 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.

Question 114. 
The nurse is part of team charged with making recommendations to create a healthy work environment. What workplace strategies would most likely support the health and well-being of workers? Select all that apply.
(a) workshops for workers nearing retirement
(b) counseling for workers exposed to traumatic events
(c) interventions for workers with substance- related problems
(d)  standard work hours that include scheduled rest periods
(e) education for workers regarding customary workplace practices
Answer:
(a) workshops for workers nearing retirement
(b) counseling for workers exposed to traumatic events
(c) interventions for workers with substance- related problems

Explanation:
(a), (b), (c) Strategies that assist and support the needs of specific workers or groups of workers most effectively promote and protect health and wellbeing. Standard hours of work and customary workplace practices do not support or address individual worker needs.

Question 115. 
When developing appropriate assignments for the staff, which client should the nurse manager judge to be at highest risk for suicide completion?
(a) an 85-year-old Caucasian man who lives alone after his wife’s death
(b) a 34-year-old single Latino woman who has recently been diagnosed with cancer
(c) a 15-year-old girl of African descent whose boyfriend broke up with her
(d)  a 52-year-old Asian man who was terminated from his job because of downsizing
Answer:
(a) an 85-year-old Caucasian man who lives alone after his wife’s death

Explanation:
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-old Caucasian male who lives alone after his wife’s death is at high risk for suicide completion.

Question 116. 
An adolescent client tells the nurse that the reason he is depressed and suicidal is that he is being bullied at school. While discussing the circumstances of the bullying, the client indicates that he is gay, which he thinks contributes to his being bullied. He tells the nurse his sexual orientation in confidence, stating that his parents do not know and that he does not want that information revealed to them. Which actions should the nurse take? Select all that apply.
(a) Give the client the crisis phone line number.
(b) Provide contact information for a support group for gay teens. 
(c) Question the client about the bullying.
(d)  Assess the client’s current status regarding suicidal thoughts/plans.
(e) Help the client develop a safety plan regarding suicidal thoughts/plans.
(f) Notify the school about the bullying without identifying the specific student.
Answer:
(a) Give the client the crisis phone line number.
(b) Provide contact information for a support group for gay teens. 
(c) Question the client about the bullying.
(d)  Assess the client’s current status regarding suicidal thoughts/plans.
(e) Help the client develop a safety plan regarding suicidal thoughts/plans.

Explanation:
(a), (b), (c), (d), (e) Exploring the bullying and sui¬cide risk 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.
 
Question 117. 
A wife brings her husband to the emergency department with a bleeding gunshot wound to the leg. The wife tells the nurse that her husband was trying to commit suicide. In what order should the nurse perform the actions from first to last? All options must be used.
(a) Assess current suicide risk.
(b) Ensure constant observation
(c) Remove potentially harmful objects from the area.
(d) Asses the gunshot wound.
Answer:
(d) Asses the gunshot wound.
(c) Remove potentially harmful objects from the area.
(b) Ensure constant observation
(a) Assess current suicide risk.

Explanation:
(d), (c), (b) (a) The nurse first assesses and treats the bleeding gunshot wound. Next, the nurse removes any objects the client could use to harm himself and ensures that the client will have constant observation. The nurse then assesses the client’s immediate risk for suicide and bases subsequent decisions on the level of risk. Once the client is safe and the wound is treated, the nurse contacts the crisis intervention team.

Question 118. 
The nurse is caring for a client who is prescribed phenelzine for depression that has not responded to other medications. When reviewing the dietary restrictions associated with this medication, the client reports that most of the client’s favorite foods are now going to be restricted. Which collaborative action would best meet the needs of the client?
(a) Review the diet restrictions with the client and make a schedule of when the preferred foods can be eaten.
(b) Identify the primary meal preparer in the family and review a meal plan with that person to decrease client stress.
(c) Report the client’s noncompliance to the health care provider so the medication can be adjusted to a previous prescription.
(d)  Collaborate with the dietitian to counsel the client on additional foods or preparation methods that are acceptable with the medication. 
Answer:
(d)  Collaborate with the dietitian to counsel the client on additional foods or preparation methods that are acceptable with the medication. 

Explanation:
Nurses rely on the expertise of other disciplines to assist in meeting client needs. Collaborating with the dietician to identify foods agreeable to the client provides client-centered care for the therapeutic plan. “Scheduling” the intake of restricted foods puts the client at risk for adverse reactions. Bypassing the client in making meal plans undermines trust and may create problems between the client and meal preparer. The client has not responded to other medications, so returning to a previous medication class will not improve the depression experienced by the client.