Question 1

Chapter 14: Depressive Disorders  MULTIPLE CHOICE   1. A patient became severely depressed when the last of the family\'s six children moved out of the home 4 months ago. The patient repeatedly says, \"No one cares about me. I\'m not worth anything.\" Which response by the nurse would be the most helpful? a. \"Things will look brighter soon. Everyone feels down once in a while.\" b. \"Our staff members care about you and want to try to help you get better.\" c. \"It is difficult for others to care about you when you repeatedly say the same negative things.\" d. \"I\'ll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you.\"

Accepted Answer

D Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is \"offering self.\" Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 263 (Table 14-4) | Page 256 (Case Study and Nursing Care Plan 14-1) TOP: Nursing Process: Implementation

Question 2

Client Needs: Psychosocial Integrity   2. A patient became depressed after the last of the family\'s six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

Accepted Answer

A Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274 TOP: Nursing Process: Outcomes Identification

Question 3

Client Needs: Psychosocial Integrity    3. A patient diagnosed with major depression says, \"No one cares about me anymore. I\'m not worth anything.\" Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient? a. \"You look nice this morning.\" c. \"I like the shirt you are wearing.\" b. \"You\'re wearing a new shirt.\" d. \"You must be feeling better today.\"

Accepted Answer

B Patients with depression usually see the negative side of things. The meaning of compliments may be altered to \"I didn\'t look nice yesterday\" or \"They didn\'t like my other shirt.\" Neutral comments such as making an observation avoid negative interpretations. Saying, \"You look nice\" or \"I like your shirt\" gives approval (non-therapeutic techniques). Saying \"You must be feeling better today\" is an assumption, which is non-therapeutic.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274 TOP: Nursing Process: Implementation

Question 4

Client Needs: Psychosocial Integrity    4. An adult diagnosed with major depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest? a. Social skills training c. Desensitization techniques b. Relaxation training classes d. Use of complementary therapy

Accepted Answer

A Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient\'s support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.  PTS: 1 DIF: Cognitive Level: Analyze (Analysis)  REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 259  TOP: Nursing Process: Planning

Question 5

Client Needs: Psychosocial Integrity   5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

Accepted Answer

B Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 263 (Table 14-3) | Page 256 (Case Study and Nursing Care Plan 14-1) TOP: Nursing Process: Planning

Question 6

Client Needs: Safe, Effective Care Environment   6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

Accepted Answer

C Cognitive behavioral therapy attempts to alter the patient\'s dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 274 TOP: Nursing Process: Planning

Question 7

Client Needs: Psychosocial Integrity    7. A patient says to the nurse, \"My life doesn\'t have any happiness in it anymore. I once enjoyed holidays, but now they\'re just another day.\" The nurse documents this report as an example of: a. dysthymia. c. euphoria. b. anhedonia. d. anergia.

Accepted Answer

B Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means \"without energy.\"  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 250 | Page 264 TOP: Nursing Process: Assessment

Question 8

Client Needs: Psychosocial Integrity    8. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today the patient says, \"I don\'t think I can keep taking these pills. They make me so dizzy, especially when I stand up.\" The nurse will: a. limit the patient\'s activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient\'s mental status examination.

Accepted Answer

C Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient\'s treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 266-267 (Table 14-6) | Page 269 (Box 14-4)  TOP: Nursing Process: Implementation

Question 9

Client Needs: Physiological Integrity   9. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug? a. Dry mouth c. Nasal congestion b. Blurred vision d. Urinary retention

Accepted Answer

D All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.  PTS: 1 DIF: Cognitive Level: Analyze (Analysis)  REF: Page 266-267 (Table 14-6) | Page 269 (Box 14-4)  TOP: Nursing Process: Assessment

Question 10

Client Needs: Physiological Integrity   10. A patient diagnosed with major depression tells the nurse, \"Bad things that happen are always my fault.\" Which response by the nurse will best assist the patient to reframe this overgeneralization? a. \"I really doubt that one person can be blamed for all the bad things that happen.\" b. \"Let\'s look at one bad thing that happened to see if another explanation exists.\" c. \"You are being extremely hard on yourself. Try to have a positive focus.\" d. \"Are you saying that you don\'t have any good things happen?\"

Accepted Answer

B By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 263 (Table 14-4) TOP: Nursing Process: Implementation

Question 11

Client Needs: Psychosocial Integrity    11. A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: a. guilt and despair. c. interest and pleasure. b. over-involvement. d. ineffectiveness and frustration.

Accepted Answer

D Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient\'s progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient\'s resistance. Guilt and despair might be seen when the nurse experiences the patient\'s feelings because of empathy. Interest is possible, but not the most likely result.  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 260-261 TOP: Nursing Process: Evaluation

Question 12

Client Needs: Psychosocial Integrity    12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

Accepted Answer

C Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 268 (Box 14-3) TOP: Nursing Process: Implementation

Question 13

Client Needs: Physiological Integrity    13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

Accepted Answer

B The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 266-267 (Table 14?6) | Page 268-269 (Table 14-7) TOP: Nursing Process: Evaluation

Question 14

Client Needs: Physiological Integrity    14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

Accepted Answer

B During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 271-272 TOP: Nursing Process: Planning

Question 15

Client Needs: Physiological Integrity    15. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

Accepted Answer

D Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 266-267 (Table 14-6) | Page 268-269 (Table 14-7) TOP: Nursing Process: Evaluation

Question 16

Client Needs: Physiological Integrity    16. Major depression resulted after a patient\'s employment was terminated. The patient now says to the nurse, \"I\'m not worth the time you spend with me. I am the most useless person in the world.\" Which nursing diagnosis applies? a. Powerlessness c. Situational low self-esteem b. Defensive coping d. Disturbed personal identity

Accepted Answer

C The patient\'s statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 250-251 | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 259 TOP: Nursing Process: Diagnosis/Analysis

Question 17

Client Needs: Psychosocial Integrity    17. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

Accepted Answer

A Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse\'s presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 261-263 (Table 14-3) TOP: Nursing Process: Implementation

Question 18

Client Needs: Psychosocial Integrity    18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, \"I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares.\" The nurse will advise the patient to: a. \"Go to the nearest emergency department immediately.\" b. \"Do not to be alarmed. Take two aspirin and drink plenty of fluids.\" c. \"Take a dose of your antidepressant now and come to the clinic to see the health care provider.\" d. \"Resume taking your antidepressants for 2 more weeks and then discontinue them again.\"

Accepted Answer

C The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 263 (Table 14-4) TOP: Nursing Process: Implementation

Question 19

Client Needs: Physiological Integrity    19. Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated \"project was a failure, just like me.\" c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, \"I feel tired all the time.\"

Accepted Answer

A Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding.  PTS: 1 DIF: Cognitive Level: Analyze (Analysis)  REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274-275 TOP: Nursing Process: Evaluation

Question 20

Client Needs: Psychosocial Integrity   20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient\'s symptoms be most acute? a. January c. June b. April d. September

Accepted Answer

A The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 271-272 TOP: Nursing Process: Assessment

Question 21

Client Needs: Psychosocial Integrity    21. A patient diagnosed with depression repeatedly tells staff, \"I have cancer. It\'s my punishment for being a bad person.\" Diagnostic tests reveal no cancer. Select the priority nursing diagnosis. a. Powerlessness c. Stress overload b. Risk for suicide d. Spiritual distress

Accepted Answer

B A patient diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.  PTS: 1 DIF: Cognitive Level: Analyze (Analysis)  REF: Page 255 | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 260 TOP: Nursing Process: Diagnosis/Analysis

Question 22

Client Needs: Psychosocial Integrity    22. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice c. Hot tea b. Orange juice d. Milk

Accepted Answer

D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 264 (Table 14-5) TOP: Nursing Process: Implementation

Question 23

Client Needs: Physiological Integrity    23. During a psychiatric assessment, the nurse observes a patient\'s facial expression is without emotion. The patient says, \"Life feels so hopeless to me. I\'ve been feeling sad for several months.\" How will the nurse document the patient\'s affect and mood? a. Affect depressed; mood flat c. Affect labile; mood euphoric b. Affect flat; mood depressed d. Affect and mood are incongruent.

Accepted Answer

B Mood refers to a person\'s self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person\'s expression, the affect is flat.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 257-258 TOP: Nursing Process: Assessment

Question 24

Client Needs: Psychosocial Integrity    24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, \"You must bathe daily.\" c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

Accepted Answer

D When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study/Nursing Care Plan 14-1) TOP: Nursing Process: Implementation

Question 25

Client Needs: Health Promotion and Maintenance   25. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, \"This medicine isn\'t working.\" The nurse\'s best intervention would be to: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

Accepted Answer

C Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 266 (Table 14-6) | Page 268 (Box 14-3)  TOP: Nursing Process: Implementation

Question 26

Client Needs: Physiological Integrity   26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed c. Smiling inappropriately b. Staring at the nurse d. Eyes pointed downward

Accepted Answer

D Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 260  TOP: Nursing Process: Assessment

Question 27

Client Needs: Psychosocial Integrity   27. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

Accepted Answer

C Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 271-272 TOP: Nursing Process: Implementation

Question 28

Client Needs: Health Promotion and Maintenance   28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of: a. hypotensive shock. c. cardiac dysrhythmia. b. hypertensive crisis. d. cardiogenic shock.

Accepted Answer

B Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.  PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 266 (Table 14-6) | Page 268-269 | Page 270 (Table 14-8)  TOP: Nursing Process: Planning

Question 29

Client Needs: Physiological Integrity   29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? a. \"They will put me to sleep during the procedure so I won\'t know what is happening.\" b. \"I might be a little dizzy or have a mild headache after each procedure.\" c. \"I will be unable to care for my children for about 2 months.\" d. \"I will avoid eating foods that contain tyramine.\"

Accepted Answer

B Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 271-272 TOP: Nursing Process: Evaluation

Question 30

Client Needs: Physiological Integrity   MULTIPLE RESPONSE   1. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

Accepted Answer

C, D, E Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.  PTS: 1 DIF: Cognitive Level: Analyze (Analysis)  REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 257 | Page 261 TOP: Nursing Process: Planning

Question 31

Client Needs: Psychosocial Integrity   2. A student nurse caring for a patient diagnosed with depression reads in the patient\'s medical record, \"This patient shows vegetative signs of depression.\" Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

Accepted Answer

A, C, D, F Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self. See relationship to audience response question.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 257-261 (Table 14-2) | Page 264 (Table 14-5)  TOP: Nursing Process: Diagnosis/Analysis

Question 32

Client Needs: Psychosocial Integrity    3. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

Accepted Answer

A, B, C The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. See relationship to audience response question.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 257 | Page 260-261 (Table 14-2) | Page 264 (Table 14-5)  TOP: Nursing Process: Implementation

Question 33

Client Needs: Psychosocial Integrity   4. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, \"I took a few extra tablets earlier today and now I feel bad.\" Which assessments are most critical? Select all that apply. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

Accepted Answer

A, D, E The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected.  PTS: 1 DIF: Cognitive Level: Apply (Application)  REF: Page 265-268 (Box 14-2) TOP: Nursing Process: Assessment

Question 34

A client with depression has not responded to a tricyclic antidepressant and outpatient electroconvulsive therapy (ECT). The health care provider prescribes selegiline (Eldepryl), and the nurse teaches the client about food to be avoided while taking this medication. Which foods identified by the client allow the nurse to conclude that the instructions have been understood? Select all that apply. 1 Fresh fish 2 Aged cheese 3 Fried chicken 4 Chocolate drinks 5 Leafy vegetables

Accepted Answer

2 & 4 Foods containing tyramine can cause hypertensive crisis and should be eliminated from the diet. These foods include pickled herring, beer, wine, chicken livers, aged or natural cheese, caffeine, cola, licorice, avocados, bananas, and bologna. Chocolate in moderation is safe for some patients, but it does contain caffeine. Overripe fruits and caffeine have high levels of tyramine, which can cause dangerous hypertension in clients taking monoamine oxidase inhibitors (MAOIs). Also, large amounts of caffeine can increase blood pressure and should be avoided. There is no need to limit the intake of fish, chicken, or leafy vegetables while taking an MAOI.

Question 35

A nurse is caring for a client who is experiencing a major depression. What feeling should the nurse anticipate that the client will likely have difficulty expressing? 1 Need for comforting 2 Anger toward others 3 Remorse for past behaviors 4 Feelings of low self-esteem

Accepted Answer

2 The client is dependent, and such individuals can never get enough attention to meet their dependent needs. This unfulfilled need causes anger, which the client has problems expressing for fear of losing the people on whom the client is dependent. The client is expressing the need for comfort. The client is able to express remorse and guilt. The client is able to express feelings of low self-esteem.

Question 36

A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display? 1 Elated affect related to reaction formation 2 Loose associations related to a thought disorder 3 Physical exhaustion related to decreased physical activity 4 Paucity of verbal expression related to slowed thought processes

Accepted Answer

4 As depression increases, thought processes become slower and verbal expression decreases due to lack of emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression. Physical exhaustion is associated with bipolar disorder, manic episode; decreased physical activity does not produce physical exhaustion.

Question 37

A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis? 1 Loss of faith in God 2 Visual hallucinations 3 Decreased social interaction 4 Ambivalent feelings about the future

Accepted Answer

3 Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Depressed clients are commonly negative and pessimistic, especially regarding their future. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders.

Question 38

Two weeks after a client has been admitted to the mental health hospital, the client\'s depression begins to lift. The nurse encourages involvement with unit activities, primarily because this type of activity: 1 Supports self-confidence 2 Provides for group interaction 3 Limits opportunities for suicide 4 Allows verbalization of repressed feelings of hostility

Accepted Answer

2 Group interaction provides a sense of belonging and fosters the assumption of responsibility. The group is not the best arena for the expression of repressed hostility. Support of self-confidence and limitation of opportunities for suicide are not ensured by group interaction.

Question 39

When caring for a client with major depression, nurses usually have the most difficulty dealing with the: 1 Client\'s lack of energy 2 Negative nonverbal responses 3 Client\'s psychomotor retardation 4 Pervasive quality of the depression

Accepted Answer

4 Depression is \"contagious\"; it affects the nurse as well as the client. The client\'s lack of energy should not make nursing care difficult. These clients usually do not offer negative responses; they offer no response.

Question 40

A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? 1 Rigidity and a narrowing of perception 2 Alternating episodes of fatigue and high energy 3 Diminished pleasure in activities and alteration in appetite 4 Excessive socialization and interest in activities of daily living

Accepted Answer

3 Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

Question 41

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1 Dementia 2 Multiple losses 3 Declines in health 4 A milestone birthday 5 An injury requiring hospitalization

Accepted Answer

2 & 3 Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

Question 42

The nurse notices that one of her clients, who has depression, is sitting by the window crying. The most appropriate response by the nurse is: 1 \"It\'s OK. No need to cry or worry while you\'re here. We all feel down now and then.\" 2 \"Please don\'t consider suicide. It really isn\'t an appropriate way out of your troubles.\" 3 \"You seem to be experiencing a sad moment. I\'ll sit here with you for a while and talk if you would like.\" 4 \"Why don\'t you go into the dayroom and join the card game going on? That\'ll take your mind off of your problems for a while.\"

Accepted Answer

3 The nurse is acknowledging that the client is feeling especially down and offering to be available for discussion or just to provide a presence. The response regarding suicide is judgmental and may discourage any effort by the client to initiate a discussion. Telling the client not to cry and suggesting a card game do not acknowledge the client\'s feelings and appear to trivialize the situation.

Question 43

When used in combination with certain foods and drugs, monoamine oxidase inhibitors (MAOIs) can cause serious side effects. Which condition could occur in clients treated with MAOIs for depression? 1 A serious drop in blood pressure 2 A serious increase in blood pressure 3 A significant increase in liver enzymes 4 A significant increase in cholesterol levels

Accepted Answer

2 MAOIs, when taken with foods high in tyramine (e.g., pickled foods, beer, wine, aged cheeses) and drugs such as antidepressants, certain pain medications, and decongestants, can cause a life-threatening increase in blood pressure. For this reason they are seldom used to treat symptoms of depression. MAOIs do not increase liver enzymes or cholesterol levels.

Question 44

A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time? 1 \"I\'m going to miss you; we\'ve become good friends.\" 2 \"I know that you\'re going to be all right when you go home.\" 3 \"Call the contact number we gave you if you have an emergency.\" 4 \"This is my phone number; call and let me know how you\'re doing.\"

Accepted Answer

3 Instructing the client to call the contact number that was provided in case of emergency demonstrates an understanding that the newly discharged client needs to have a support system. Clients need to feel that in a crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead to help the client become a functioning being again. \"I know you\'re going to be all right when you go home\" provides false reassurance; the nurse does not know this. \"This is my phone number; call and let me know how you\'re doing\" is unprofessional and blurs the roles of nurse and client.

Question 45

A client with major depression that includes psychotic features tells the nurse, \"All of my relatives have been killed because I\'ve been sinful and need to be punished.\" What is the primary focus of nursing interventions? 1 Protecting the client against any suicidal impulses 2 Supporting the client\'s interest in the outside world 3 Helping the client manage the concern for family members 4 Reassuring the client that past behaviors are not being punished

Accepted Answer

1 Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client\'s safety is the focus of nursing interventions. Supporting the client\'s interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client\'s belief.

Question 46

A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity? 1 Find solitary pursuits that the client can enjoy. 2 Speak to the client about the importance of entering into activities. 3 Ask the health care provider to speak to the client about participating.  4 Invite another client to take part in a joint activity with the nurse and the client.

Accepted Answer

4 Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the health care provider to speak to the client about participating transfers the nurse\'s responsibility to the health care provider.

Question 47

A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug? 1 It must be given with milk and crackers to avoid hyperacidity and discomfort. 2 Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. 3 The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. 4 The blood level should be checked weekly for 3 months to monitor for an appropriate level.

Accepted Answer

3 Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with the monoamine oxidase inhibitors. Weekly blood level checks are not necessary with fluoxetine.

Question 48

A depressed client has been prescribed a tricyclic antidepressant. How long should the nurse inform the client that it will take before the client notices a significant change in the depression? 1 4 to 6 days 2 2 to 4 weeks 3 5 to 6 weeks 4 12 to 16 hours

Accepted Answer

2 It takes 2 to 4 weeks for the tricyclic antidepressant to reach a therapeutic blood level. Four to 6 days and 12 to 16 hours are both too short of time spans for a therapeutic blood level of the drug to be achieved. Improvement in depression should be demonstrated earlier than 5 to 6 weeks.

Question 49

A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention? 1 Introducing the client to one other client 2 Requiring participation in therapy sessions 3 Encouraging interaction with others in small groups 4 Conveying an attitude of concern that is not intrusive

Accepted Answer

4 Conveying concern without being intrusive will allow the client to control the pace of development of the nurse-client relationship. Depressed clients are unable to move into relationships with other clients or group situations. It is too early for therapy sessions; the first thing that must be established is a trusting nurse-client relationship.

Question 50

A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, \"Things always seem the same. They never change.\" The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? 1 Outbursts of anger 2 Focused concentration 3 Preoccupation with delusions 4 Intense interpersonal relationships

Accepted Answer

1 Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.

Question 51

A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when he states that one major disadvantage of ECT is that: 1 The seizures may cause bone fractures. 2 Relief of symptoms requires many weeks of treatment. 3 Memory is impaired just before and after the treatment. 4 Loss of mental function occurs and continues for a long time.

Accepted Answer

3 Impaired memory is an expected side effect of the therapy. Succinylcholine (Anectine) prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.

Question 52

A client is admitted with the diagnosis of borderline personality disorder/possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client? 1 Degree of anger 2 Potential for suicide 3 Level of intelligence 4 Ability to test reality

Accepted Answer

2 Depressed clients may use suicide as the ultimate escape from feelings; ensuring safety by protecting the client from self-harm is the priority. Although degree of anger is important, it is not the priority. Assessment of the level of intelligence is unnecessary; clients with a diagnosis of borderline personality disorder are usually of average intelligence. Clients with a diagnosis of borderline personality disorder are more concerned with satisfying their needs than testing reality; they are more concerned about themselves than others or the environment.

Question 53

When teaching parents about childhood depression the nurse should say that it: 1 May appear as acting-out behavior 2 Does not respond to conventional treatment 3 Looks almost identical to adult depression 4 Is short in duration and has an early resolution

Accepted Answer

1 Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may indicate an underlying depression. Adult and childhood depression may be manifested in different ways. Childhood depression is not necessarily short and requires treatment. Many conventional therapies for adults with depression, including medication, are effective for children with depression.

Question 54

A client is admitted to the hospital with a diagnosis of depression. What clinical manifestations of depression does the nurse expect when assessing this client? 1 Flight of ideas 2 Suspicion of others 3 Psychomotor retardation 4 Intrusive social behaviors

Accepted Answer

3 Both thought and motor activity, which require physical and psychic energy, are commonly slowed when someone is depressed. Flight of ideas is associated with manic behavior because it requires psychic energy. Suspicion is associated with paranoid ideation and is less common with depression. Intrusive social behaviors are associated with manic behavior.

Question 55

During a home visit the nurse obtains information about a postpartum client\'s behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1 Lethargy 2 Ambivalence 3 Emotional lability 4 Increased appetite 5 Long periods of sleep

Accepted Answer

1,2,3 Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is associated with depression.

Question 56

An effective mood-stabilizing drug used in clients with bipolar disorder in the acute treatment of mania and prevention of recurrent mania and depressive episodes is: 1 Doxepin (Sinequan) 2 Clozapine (Clozaril) 3 Amitriptyline (Elavil) 4 Lithium carbonate (Lithium)

Accepted Answer

4 Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to calm acute manic symptoms and relieve recurrent mania. Doxepin and amitriptyline are antidepressants used to treat depression but not mania. Clozaril is an antipsychotic medication used to control hallucinations and delusions in patients with psychosis but is not a first-line drug because of its side effects, which include seizures and significant weight gain.

Question 57

A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Select all that apply. 1 Insomnia 2 Irritability 3 Excessive eating 4 Decreased libido 5 Financial irresponsibility

Accepted Answer

1,2,5 During a manic episode there is a decreased need for sleep and clients do not feel tired. During a manic episode the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode there is a decrease in appetite. The client\'s increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode. During a manic episode impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences.

Question 58

A client has been found to have bipolar disorder and is being prescribed lithium carbonate (Lithium). In light of the information shown, the nurse provides teaching to the client. Select all that apply.   TSH (10) Sodium (132) 1 Lithium can affect WBC production and therefore increases her risk for infection. 2 Her current thyroid function will require frequent assessments while she takes lithium. 3 Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level. 4 Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy. 5 The current hemoglobin and hematocrit call for regular monitoring is needed once the lithium level is stabilized.

Accepted Answer

2,3  Lithium carbonate therapy can negatively affect thyroid function; the client\'s current TSH is at the high normal level and so frequent checks are appropriate. Low serum sodium levels would result in the kidneys\' reabsorbing the lithium; this situation would lead to lithium toxicity. The health care provider must first be notified of the lab result. Lithium is not known to have a negative effect on WBC, platelet, or RBC production.  Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

Question 59

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1 Passivity 2 Dysphoria 3 Anhedonia 4 Grandiosity 5 Talkativeness 6 Distractibility

Accepted Answer

4,5,6  Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client\'s rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Dysphoria, a depressed, sad mood, is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.

Question 60

A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply. 1 Touching the client to provide reassurance 2 Providing a structured environment for the client 3 Ensuring that the client\'s nutritional needs are met 4 Engaging the client in conversation about current affairs 5 Designing activities that require the client to maintain contact with reality

Accepted Answer

2,3  Structure tends to decrease agitation and anxiety and to increase the client\'s feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.

Question 61

A client is receiving carbamazepine (Tegretol) for the treatment of a manic episode of bipolar disorder. What should the nurse include when planning client teaching about this medication? Select all that apply. 1 \"You have to eat a low-sodium diet every day.\" 2 \"You\'ll have to take a diuretic with this medication.\" 3 \"You\'ll have to take this medication for the rest of your life.\" 4 \"You may want to suck on hard candy when you get a dry mouth.\" 5 \"We\'ll need to test your blood often during the first few weeks of therapy.\"

Accepted Answer

4,5 Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. Carbamazepine can cause severe bone marrow depression in the early phase of therapy. Also, the drug level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required; nor is a diuretic. The client may or may not have to take the medication for life.

Question 62

A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment? 1 Doing a needlepoint project 2 Joining a brief swimming competition 3 Walking around the facility with a nurse 4 Playing a board game with another client

Accepted Answer

3 Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client\'s anxiety. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.

Question 63

A 25-year-old woman with the diagnosis of bipolar disorder, manic episode, is admitted to the psychiatric unit. A nurse on the unit reviews the admission information provided by the client\'s husband and assesses the client. In light of the information in the chart, what is an appropriate nursing intervention? 1 Assigning the client to a private room 2 Suggesting that the client play cards with several other clients 3 Encouraging the development of insight through introspection 4 Having the client sit at the communal dining table during meals

Accepted Answer

1 During the acute phase of mania, care should be focused on maintaining the safety of the client and others and decreasing the client\'s energy expenditure. Hypersexuality is often associated with the manic episode of bipolar disorder. Obtaining sexual pleasure by exposing the genitals (exhibitionism) is a paraphilia. A private room protects the other clients and provides privacy for the client. The client is too hyperactive to engage in group activities, and hypersexual behavior may precipitate anxiety in the other clients. Also, manic clients can be overly competitive, which may disturb the other clients. Activities at this time should be solitary or one-on-one with the nurse or nursing assistant. Manic clients have flight of ideas (rapid racing thoughts) and are easily distracted. Introspection and the development of insight cannot occur during this phase of the illness. The hyperactive client will not have the self-control to sit long enough to eat a meal. The nurse should provide finger foods and other portable foods (e.g., sandwich, fruit, milkshake) and encourage the intake of food with short declarative statements that direct the client to eat (e.g., \"Finish your sandwich,\" \"Eat this banana\").

Question 64

Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. The most important intervention for the client who is given a PRN medication and confined to involuntary seclusion is to: 1 Continue intensive nursing interactions. 2 Evaluate the client\'s progress toward self-control. 3 Determine whether any staff member has been injured. 4 Observe the client for side effects of the medication given to the client.

Accepted Answer

2 For the safety of the client and everyone on the unit, improvement in a client\'s level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client\'s behavior to escalate. The nurse\'s prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client\'s level of self-control.

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