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MH, Exam 2 success

question

Which situation supports the biological theory of the development of bipolar affective disorder? 1. A client is prescribed a selective serotonin reuptake inhibitor and then exhibits impulsive behaviors, expansive mood, and flight of ideas. 2. A client has three jobs, which require increased amounts of energy and the ability to multitask. 3. A client experiences thoughts of negative self-image and then expresses grandiosity when discussing abilities at work. 4. A client has been raised in a very chaotic household where there was a lack of impulse control related to excessive spending.
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1. A client is prescribed a selective serotonin reuptake inhibitor and then exhibits impulsive behaviors, expansive mood, and flight of ideas. 1. When a client diagnosed with bipolar affective disorder (BPAD) is prescribed a selective serotonin reuptake inhibitor, there is potential for alterations in neurochemicals that could generate a manic episode. Alterations in neurochemicals support a biological theory in the development of BPAD..
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7. Which of the following medications can cause confusion, depression, and increased anxiety? Select all that apply. 1. Codeine (generic). 2. Dextromethorphan (Robitussin). 3. Loratadine (Claritin). 4. Levodopa (Sinemet). 5. Pseudoephedrine (Sudafed)
answer

Codeine (generic). Levodopa (Sinemet).
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A client rates anxiety at 8 out of 10 on a scale of 1 to 10, is restless, and has narrowed perceptions. Which of the following medications would appropriately be prescribed to address these symptoms? Select all that apply. 1. Chlordiazepoxide (Librium). 2. Clonazepam (Klonopin). 3. Lithium carbonate (lithium). 4. Clozapine (Clozaril). 5. Oxazepam (Serax).
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Chlordiazepoxide (Librium) Clonazepam (Klonopin). Oxazepam (Serax). all these three meds are benzodiazepines classified as antianxirty meds.
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11. A client diagnosed with generalized anxiety disorder is placed on clonazepam (Klonopin) and buspirone (BuSpar). Which client statement indicates teaching has been effective? 1. The client verbalizes that the clonazepam (Klonopin) is to be used for long-term therapy in conjunction with buspirone (BuSpar). 2. The client verbalizes that buspirone (BuSpar) can cause sedation and should be taken at night. 3. The client verbalizes that clonazepam (Klonopin) is to be used short-term until the buspirone (BuSpar) takes full effect. 4. The client verbalizes that tolerance can result with long-term use of buspirone (BuSpar)
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The client verbalizes that clonazepam (Klonopin) is to be used short-term until the buspirone (BuSpar) takes full effect.
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In which situation would benzodiazepines be prescribed appropriately? 1. Long-term treatment of posttraumatic stress disorder, convulsive disorder, and alcohol withdrawal. 2. Short-term treatment of generalized anxiety disorder, alcohol withdrawal, and preoperative sedation. 3. Short-term treatment of obsessive-compulsive disorder, skeletal muscle spasms, and essential hypertension. 4. Long-term treatment of panic disorder, alcohol dependence, and bipolar affective disorder: manic episode.
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Short-term treatment of generalized anxiety disorder, alcohol withdrawal, and preoperative sedation. benzodiazepines are prescribed short term because of their additive properties.
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A client recently diagnosed with generalized anxiety disorder is prescribed clonazepam (Klonopin), buspirone (BuSpar), and citalopram (Celexa). Which assessment related to the concurrent use of these medications is most important? 1. Monitor for signs and symptoms of worsening depression and suicidal ideation. 2. Monitor for changes in mental status, diaphoresis, tachycardia, and tremor. 3. Monitor for hyperpyresis, dystonia, and muscle rigidity. 4. Monitor for spasms of face, legs, and neck and for bizarre facial movement
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Monitor for changes in mental status, diaphoresis, tachycardia, and tremor. it is important for the nurse to monitor for the serotonin syndrome symptoms
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Which of the following symptoms are seen when a client abruptly stops taking diazepam (Valium)? Select all that apply. 1. Insomnia. 2. Tremor. 3. Delirium. 4. Dry mouth. 5. Lethargy
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1. Insomnia. 2. Tremor. 3. Delirium Dry mouth and Lethargy are side effects of the benzodiazepines.
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which of the following are examples of anticholinergic side effects from tricyclic antidepressants? Select all that apply. 1. Urinary hesitancy. 2. Constipation. 3. Blurred vision. 4. Sedation. 5. Weight gain.
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1. Urinary hesitancy. 2. Constipation. 3. Blurred vision. sedation and weight gain is SE of antihistamine.
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A client diagnosed with major depressive disorder and experiencing suicidal ideation is showing signs of anxiety. Alprazolam (Xanax) is prescribed. Which assessment should be prioritized? 1. Monitor for signs and symptoms of physical and psychological withdrawal. 2. Teach the client about side effects of the medication, and how to handle these side effects. 3. Assess for nausea, and give the medication with food if nausea occurs. 4. Ask the client to rate his or her mood on a mood scale, and monitor for suicidal ideations.
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Ask the client to rate his or her mood on a mood scale, and monitor for suicidal ideations alprazolam(xanax) is a CNS depressant, and it is important for the nurse to monitor for worsening depressive symptoms and possible worsening of suicidal ideation.
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A client admitted to the hospital with suicidal ideations is prescribed paroxetine (Paxil). The client has a nursing diagnosis of knowledge deficit R/T newly prescribed medication. Which nursing intervention addresses this client’s problem? 1. Teaching client regarding risk for discontinuation syndrome. 2. Maintaining safe milieu and monitoring for suicidal ideation. 3. Assessing mood using a 1-to-10 mood scale. 4. Reinforcing the need to take the medication on an empty stomach.
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1. Teaching client regarding risk for discontinuation syndrome. dizziness, lethargy, headache, and nausea are signs of discontinuation syndrome, which can occur when a long term therapy with SSRI is stopped abruptly. it is important for the client to know this to understand the importance of taking the medication as prescribed.
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Which situation would place a client at high risk for a life-threatening hypertensive crisis? 1. A client is prescribed tranylcypromine (Parnate) and eats chicken salad. 2. A client is prescribed isocarboxazid (Marplan) and drinks hot chocolate. 3. A client is prescribed venlafaxine (Effexor) and drinks wine. 4. A client is prescribed phenelzine (Nardil) and eats fresh roasted chicken
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A client is prescribed isocarboxazid (Marplan) and drinks hot chocolate. isocarboxazid (Marplan) is an AMOI and patients taking AMOI should avoid aged cheese, wine, beer, chocolate, colas, coffee, tea, sour cream, beef/chicken liver canned figs, soy sauce, overripe and fermented foods, pickled herring, preserved sausage, smoked and processed ,meats, yogurt, yeast products, old remedies or diet pills.
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A client has been taking bupropion (Wellbutrin) for more than 1 year. The client has been in a car accident with loss of consciousness and is brought to the emergency department. For which reason would the nurse question the continued use of this medication? 1. The client may have a possible injury to the gastrointestinal system. 2. The client is at risk for seizures from a potential closed head injury. 3. The client is at increased risk of bleeding while taking bupropion. 4. The client may experience sedation from bupropion, making assessment difficult
answer

The client is at risk for seizures from a potentially closed head injury. buspirone lowers the seizure threshold. and is contraindicated for clients who have increased potential for seizure such as head trauma injury.
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A client experiencing suicidal ideations with a plan to overdose on medications is admitted to an in-patient psychiatric unit. Mirtazapine (Remeron) is prescribed. Which nursing intervention takes priority? 1. Remind the client that medication effectiveness may take 2 to 3 weeks. 2. Teach the client to take the medication with food to avoid nausea. 3. Check the client’s blood pressure every shift to monitor for hypertension. 4. Monitor closely for signs that the client might be “cheeking” medication
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Monitor closely for signs that the client might be “cheeking” medication clients came to the in patient psychiatric unit with a plan to overdose, it is important that the nurse monitor for checking and hoarding the med. the client may cheek and hoard the med to take an overdose at another time.
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A client on an in-patient psychiatric unit has been prescribed tranylcypromine (Parnate) 30 mg QD. Which client statement indicates that discharge teaching has been successful? 1. “I can’t wait to order liver and fava beans with a nice Chianti.” 2. “Chicken teriyaki with soy sauce, apple sauce, and tea sound great.” 3. “I have been craving a hamburger with lettuce and onion, potato chips, and milk.” 4. “For lunch tomorrow I’m having bologna and cheese, a banana, and a cola.”
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3. “I have been craving a hamburger with lettuce and onion, potato chips, and milk.” all of these foods are safe when taking an AMOI. tranylcypromine (Parnate) is an AMOI.
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A client recently prescribed venlafaxine (Effexor) 37.5 mg bid complains of dry mouth, orthostatic hypotension, and blurred vision. Which nursing intervention is appropriate? 1. Hold the next dose, and document symptoms immediately. 2. Reassure the client that side effects are transient, and teach ways to deal with them. 3. Call the physician to receive an order for benztropine (Cogentin). 4. Notify the dietary department about restrictions related to monoamine oxidase inhibitors.
answer

Reassure the client that side effects are transient, and teach ways to deal with them. such as ice chip, sip a small amount of water, chew sugar-free gum or candy to moisten the dry mouth, encourage the client to change the position slowly, and use moisterizing eye drops.
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A client comes to the hospital complaining of depression with suicidal ideations. The physician prescribes citalopram (Celexa). Approximately 4 days later, the client has pressured speech and is noted wearing heavy makeup. What may be a potential reason for this client behavior? 1. The client is in a manic episode caused by the citalopram (Celexa). 2. The client is showing improvement and is close to discharge. 3. The client is masking depression in an attempt to get out of the hospital. 4. The client has “cheeked” medications and taken them all at once in an attempt to overdose.
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. The client is in a manic episode caused by the citalopram (Celexa). an SSRI can cause alterations in neurotransmitters and trigger a hypomanic or manic episode.
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Lithium carbonate (lithium) is to mania as clozapine (Clozaril) is to: 1. Anxiety. 2. Depression. 3. Psychosis. 4. Akathisia.
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psychosis clozapine (clozaril) is atypical antipsychotic to treat thought disorders such as pscychosis.
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42. A client prescribed lithium carbonate (lithium) 300 mg QAM and 600 mg QHS enters the emergency department experiencing impaired consciousness, nystagmus, and arrhythmias. Earlier today the client had two seizures. Which serum lithium level would the nurse expect to assess? 1. 3.7 mEq/L. 2. 3.0 mEq/L. 3. 2.5 mEq/L. 4. 1.9 mEq/L
answer

3.7 mEq/L serum level greater than 3.5 may show signs such as impaired consciousness, nystagmus, seizures, coma, oliguria, arrhythmias, myocardial infection, or cardiocascular collapse.
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43. A client is newly prescribed lithium carbonate (lithium). Which teaching point by the nurse takes priority? 1. “Make sure your salt intake is consistent.” 2. “Limit your fluid intake to 2000 mL/day.” 3. “Monitor your caloric intake because of potential weight gain.” 4. “Get yourself in a daily routine to assist in avoiding relapse.”
answer

“Make sure your salt intake is consistent.”
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. Which list contains medications that the nurse may see prescribed to treat clients diagnosed with bipolar affective disorder? 1. Lithium carbonate (lithium), loxapine (Loxitane), and carbamazepine (Tegretol). 2. Gabapentin (Neurontin), thiothixene (Navane), and clonazepam (Klonopin). 3. Divalproex sodium (Depakote), verapamil (Calan), and olanzapine (Zyprexa). 4. Lamotrigine (Lamictal), risperidone (Risperdal), and benztropine (Cogentin).
answer

Divalproex sodium (Depakote), verapamil (Calan), and olanzapine (Zyprexa). Divalproex sodium (Depakote) is an anticonvulsant verapamil (Calan), calcium channel blocker are used in long term treatment of bipolar olanzapine is antipsychotic for the treatment of acute manic episode.
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45. The nurse is evaluating lab test results for a client prescribed lithium carbonate (lithium). The client’s lithium level is 1.9 mEq/L. Which nursing intervention takes priority? 1. Give next dose because the lithium level is normal for acute mania. 2. Hold the next dose, and continue the medication as prescribed the following day. 3. Give the next dose after assessing for signs and symptoms of lithium toxicity. 4. Immediately notify the physician, and hold the dose until instructed further.
answer

Immediately notify the physician, and hold the dose until instructed further. the maintanence level is 0.6 to 1.2
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46. A client prescribed lithium carbonate (lithium) 300 mg bid 3 months ago is brought into the hospital emergency department with mental confusion, excessive diluted urine output, and consistent tremors. Which lithium level would the nurse expect? 1. 1.2 mEq/L. 2. 1.5 mEq/L. 3. 1.7 mEq/L. 4. 2.2 mEq/L.
answer

2.2 mEq/L. between 2.0 to 3.5 the client may exhibit signs such as the excessive output of diluted urine, increased tremors, muscular irritability, psychomotor retardation, mental confsion and giddiness.
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47. A client on an in-patient psychiatric unit is prescribed lamotrigine (Lamictal) 50 mg QD. After client teaching, which client statement reflects understanding of important information related to lamotrigine? 1. “I know the importance of reporting any alteration in my medication schedule.” 2. “I will schedule an appointment for my blood to be drawn at the lab next week.” 3. “I will call the doctor immediately if my temperature rises above 100°F.” 4. “I will stop my medication if I start having muscle rigidity of my face or neck.”
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I know the importance of reporting any alteration in my medication schedule.”
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48. A client diagnosed with bipolar affective disorder is prescribed divalproex sodium (Depakote). Which of the following lab tests would the nurse need to monitor throughout drug therapy? Select all that apply. 1. Platelet count and bleeding time. 2. Aspartate aminotransferase (AST). 3. Fasting blood sugar (FBS). 4. Alanine aminotransferase (ALT). 5. Valproic acid level.
answer

Platelet count and bleeding time. Aspartate aminotransferase (AST). Alanine aminotransferase (ALT). Valproic acid level.
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49. A client diagnosed with bipolar affective disorder is prescribed carbamazepine (Tegretol). The client exhibits nausea, vomiting, and anorexia. Which is an appropriate nursing intervention at this time? 1. Stop the medication, and notify the physician. 2. Hold the next dose until symptoms subside. 3. Administer the next dose with food. 4. Ask the physician for a stat carbamazepine (Tegretol) level
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Administer the next dose with food.
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Which action should be taken by the clinician when there is reasonable certainty that a client is going to harm someone? Select all that apply. 1. Assess the threat of violence toward another. 2. Identify the person being threatened. 3. Notify the identified victim. 4. Notify only law enforcement authorities to protect confidentiality. 5. Consider petitioning the court for continued commitment.
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1. Assess the threat of violence toward another. 2. Identify the person being threatened. 3. Notify the identified victim. 5. Consider petitioning the court for continued commitment.
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8. In which situation does a health-care worker have a duty to warn a potential victim? 1. When clients manipulate and split the staff and are a danger to self. 2. When clients curse at family members during visiting hours. 3. When clients exhibit paranoid delusions and auditory or visual hallucinations. 4. When clients make specific threats toward someone who is identifiable.
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When clients make specific threats toward someone who is identifiable.
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9. A client’s husband is visiting his wife during visiting hours. A nurse walking by hears him verbally abuse the client. Which nursing response is appropriate? 1. Ask the client to ask her husband to leave the unit. 2. Remind the client’s husband of the unit rules. 3. Ask the husband to come to the nurse’s station to talk about his feelings. 4. Sit with the client and her husband to begin discussing anger issues.
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Remind the client’s husband of the unit rules.
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19. On an in-patient unit, a client is isolating self in room and refusing to attend group therapy. Which is an appropriate short-term outcome for this client? 1. Client participation will be expected in one group session. 2. Provide opportunities for the client to increase self-esteem by discharge. 3. The client will communicate with staff by the end of the 3-to-11 shift. 4. The client will demonstrate socialization skills when in the milieu.
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The client will communicate with staff by the end of the 3-to-11 shift.
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20. A client on an in-patient psychiatric unit is sarcastic to staff and avoids discussions in group therapy. Which long-term outcome is appropriate for this client? 1. The client will not injure himself or herself or someone else. 2. The client will express feelings of anger in group therapy by end of shift. 3. The client will take responsibility for his or her own feelings. 4. The client will participate in out-patient therapy within 2 weeks of discharge.
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The client will participate in out-patient therapy within 2 weeks of discharge.
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26. Which immediate biological responses are associated with fight-or-flight syndrome? 1. Bronchioles in the lungs dilate, and respiration rate increases. 2. Vasopressin increases fluid retention and increases blood pressure. 3. Thyrotropic hormone stimulates the thyroid gland to increase metabolic rate. 4. Gonadotropins cause a decrease in secretion of sex hormone and produce impotence. Crisis Intervent
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Bronchioles in the lungs dilate, and respiration rate increases.
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25. A nurse on an in-patient psychiatric unit is assessing a client at risk for acting out behaviors. Which behavioral symptom would the nurse expect to be exhibited? 1. Invasion of personal space. 2. Flushed face. 3. Increased anxiety. 4. Misinterpretation of stimuli.
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Invasion of personal space.
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24. Which is an example of a physiological response to a panic level of anxiety? 1. Inability to focus. 2. Loss of consciousness. 3. 4. Possible psychosis.
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Dilated pupils.
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23. Which is an example of a behavioral response to a moderate level of anxiety? 1. Narrowing perception. 2. Heart palpitations. 3. Limited attention span. 4. Restlessness.
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Restlessness. Narrowing perception.and limited attention span are cognitive not behavior. a heart palpitation is physiological not behavior.
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22. Which is an example of a cognitive response to a mild level of anxiety? 1. Increased respirations. 2. Feelings of horror or dread. 3. Pacing the hall. 4. Increased concentration.
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Increased concentration
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A girl is jealous of her best friend for winning the scholarship she herself expected. She agrees to meet her friend for lunch and then arrives 1 hour late, apologizing and begging forgiveness. The girl is displaying which behavior? 1. Self-assertion. 2. Passive-aggressiveness. 3. Splitting. 4. Omnipotence.
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Passive-aggressiveness.
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34. The nurse should assess which of the following client behaviors when completing a risk assessment? Select all that apply. 1. Past history of violence. 2. Disturbed thought process. 3. Invasion of personal space. 4. Flushed face. 5. Self-mutilation
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Past history of violence. Invasion of personal space. Self-mutilation
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35. A client with rigid posture and raised voice uses profanity while demanding to use the phone. Which nursing diagnosis is a priority? 1. Risk for injury toward others R / T anxiety AEB rigid posture and profanity. 2. Ineffective coping R / T inability to express feelings AEB aggressive demeanor. 3. Disturbed thought process R / T altered perception AEB demanding behaviors. 4. Social isolation R / T anger AEB inability to get along with staff.
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Ineffective coping R / T inability to express feelings AEB aggressive demeanor.
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36. A student is learning about “prodromal syndrome.” Which student statement indicates that learning has occurred? 1. “Behaviors associated with prodromal syndrome necessitate immediate action by the nurse.” 2. “Prodromal syndrome occurs after a client’s outburst.” 3. “Staff cannot assist clients who are experiencing a prodromal syndrome to gain control.” 4. “Very few symptoms are associated with a prodromal syndrome.”
answer

“Behaviors associated with prodromal syndrome necessitate immediate action by the nurse.”
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37. On an in-patient psychiatric unit, a nurse is completing a risk assessment on a newly admitted client experiencing agitation. Which cognitive symptom expressed by the client would the nurse document? 1. Past history of violence. 2. Disturbed thought process. 3. History of throwing objects on the unit. 4. Flushed face.
answer

2. Disturbed thought process.
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38. In group therapy, an angry client becomes increasingly restless and irritable and shouts at the facilitator. Which nursing diagnosis takes priority? 1. Risk for injury toward others R / T inability to deal with frustration. 2. Ineffective coping R / T inability to express feelings AEB raised voice. 3. Anxiety R / T topic at hand AEB restlessness in group therapy. 4. Social isolation R / T intimidation of others AEB solitary activities.
answer

Risk for injury toward others R / T inability to deal with frustration.
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39. A client is transported to the emergency department by emergency medical services for head and abdominal trauma sustained in a physical altercation with a family member. In this situation, which nursing diagnosis would take priority? 1. Risk for other-directed violence R / T anger toward a family member. 2. Poor self-esteem R / T altered family processes. 3. Risk for injury R / T possible complications secondary to trauma. 4. Anxiety R / T injuries AEB tremors and crying.
answer

Risk for injury R / T possible complications secondary to trauma.
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40. An agency nurse is coming to an in-patient psychiatric unit for the first time. The charge nurse of the unit would assign which client to this nurse? 1. A client newly admitted for suicidal ideations with a plan to jump off a bridge. 2. A client admitted 2 days ago for alcohol detoxification with a history of seizures. 3. A client grimacing and pacing the halls with a grim defiant affect 4. A client starting clozapine (Clozaril) therapy to treat auditory hallucinations.
answer

A client newly admitted for suicidal ideations with a plan to jump off a bridge.
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1. From a cognitive theory perspective, which is a possible cause of panic disorder? 1. Inability of the ego to intervene when conflict occurs. 2. Abnormal elevations of blood lactate and increased lactate sensitivity. 3. Increased involvement of the neurochemical norepinephrine. 4. Distorted thinking patterns that precede maladaptive behaviors.
answer

Distorted thinking patterns that precede maladaptive behaviors.
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2. An overuse or ineffective use of ego defense mechanisms, which results in a maladaptive response to anxiety, is an example of the ___________________ theory of generalized anxiety disorder development.
answer

psychodynamic theory
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3. A client diagnosed with posttraumatic stress disorder is close to discharge. Which client statement would indicate that teaching about the psychosocial cause of posttraumatic stress disorder was effective? 1. “I understand that the event I experienced, how I deal with it, and my support system all affect my disease process.” 2. “I have learned to avoid stressful situations as a way to decrease emotional pain.” 3. “So, natural opioid release during the trauma caused my body to become ‘addicted.'” 4. “Because of the trauma, I have a negative perception of the world and feel hopeless.”
answer

“I understand that the event I experienced, how I deal with it, and my support system all affect my disease process.”
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4. Counselors have been sent to a location that has experienced a natural disaster to assist the population to deal with the devastation. This is an example of __________________ prevention.
answer

primary intervention
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5. Which of the following statements explains the etiology of obsessive-compulsive disorder (OCD) from a biological theory perspective? 1. Individuals diagnosed with OCD have weak and underdeveloped egos. 2. Obsessive and compulsive behaviors are a conditioned response to a traumatic event. 3. Regression to the pre-Oedipal anal sadistic phase produces the clinical symptoms of OCD. 4. Abnormalities in various regions of the brain have been implicated in the cause of OCD.
answer

Abnormalities in various regions of the brain have been implicated in the cause of OCD.
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6. After being diagnosed with pyrophobia, the client states, “I believe this started at the age of 7 when I was trapped in a house fire.” When examining theories of phobia etiology, this situation would be reflective of ____________ theory.
answer

learning
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7. A client diagnosed with social phobia has an outcome that states, “Client will voluntarily participate in group activities with peers by day 3.” Which would be an appropriate intrapersonal intervention by the nurse to assist the client to achieve this outcome? 1. Offer PRN lorazepam (Ativan) 1 hour before group begins. 2. Attend group with client to assist in decreasing anxiety. 3. Encourage discussion about fears related to socialization. 4. Role-play scenarios that may occur in group to decrease anxiety.
answer

Encourage discussion about fears related to socialization.
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8. Using psychodynamic theory, which intervention would be appropriate for a client diagnosed with panic disorder? 1. Encourage the client to evaluate the power of distorted thinking. 2. Ask the client to include his or her family in scheduled therapy sessions. 3. Discuss the overuse of ego defense mechanisms and their impact on anxiety. 4. Teach the client about the effect of blood lactate level as it relates to the client’s panic attacks.
answer

Discuss the overuse of ego defense mechanisms and their impact on anxiety.
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9. Which nursing diagnosis reflects the intrapersonal theory of the etiology of obsessive compulsive disorder? 1. Ineffective coping R /T punitive superego. 2. Ineffective coping R /T active avoidance. 3. Ineffective coping R /T alteration in serotonin. 4. Ineffective coping R /T classic conditioning.
answer

Ineffective coping R /T punitive superego. punitive superego: Self-punishment (or the “need for punishment”) is a tendency, postulated by Freud, which drives certain subjects to inflict suffering upon themselves and search out painful situations, for the purpose of neutralizing a feeling of unconscious guilt.
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10. The nurse is using an intrapersonal approach to assist a client in dealing with survivor’s guilt. Which intervention would be appropriate? 1. Encourage the client to attend a survivor’s group. 2. Encourage expression of feelings during one-to-one interactions with the nurse. 3. Ask the client to challenge the irrational beliefs associated with the event. 4. Administer regularly scheduled paroxetine (Paxil) to deal with depressive symptoms.
answer

Encourage expression of feelings during one-to-one interactions with the nurse.
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1. A client diagnosed with posttraumatic stress disorder states to the nurse, “All those wonderful people died, and yet I was allowed to live.” Which is the client experiencing? 1. Denial. 2. Social isolation. 3. Anger. 4. Survivor’s guilt.
answer

. Survivor’s guilt.
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Clients diagnosed with obsessive-compulsive disorder commonly use which mechanism? 1. Suppression. 2. Repression. 3. Undoing. 4. Denial.
answer

Undoing
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A client diagnosed with obsessive-compulsive disorder is newly admitted to an inpatient psychiatric unit. Which cognitive symptom would the nurse expect to assess? 1. Compulsive behaviors that occupy more than 4 hours per day. 2. Excessive worrying about germs and illness. 3. Comorbid abuse of alcohol to decrease anxiety. 4. Excessive sweating and an increase in blood pressure and pulse.
answer

Excessive worrying about germs and illness.
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Which of the following symptom assessments would validate the diagnosis of generalized anxiety disorder? Select all that apply. 1. Excessive worry about items difficult to control. 2. Muscle tension. 3. Hypersomnia. 4. Excessive amounts of energy. 5. Feeling “keyed up” or “on edge.”
answer

Excessive worry about items difficult to control. Muscle tension. Feeling “keyed up” or “on edge.”
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Which assessment data would support a physician’s diagnosis of an anxiety disorder in a client? 1. A client experiences severe levels of anxiety in one area of functioning. 2. A client experiences an increased level of anxiety in one area of functioning for a 6-month period. 3. A client experiences increased levels of anxiety that affect functioning in more than one area of life over a 6-month period. 4. A client experiences increased levels of anxiety that affect functioning in at least three areas of life.
answer

A client experiences increased levels of anxiety that affect functioning in more than one area of life over a 6-month period.
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Anxiety is a symptom that can result from which of the following physiological conditions? Select all that apply. 1. Chronic obstructive pulmonary disease. 2. Hyperthyroidism. 3. Hypertension. 4. Diverticulosis. 5. Hypoglycemia.
answer

Chronic obstructive pulmonary disease. Hyperthyroidism. Hypoglycemia.
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A client with a history of generalized anxiety disorder enters the emergency department complaining of restlessness, irritability, and exhaustion. Vital signs are blood pressure 140/90 mm Hg, pulse 96, and respirations 20. Based on this assessed information, which assumption would be correct? 1. The client is exhibiting signs and symptoms of an exacerbation of generalized anxiety disorder. 2. The client’s signs and symptoms are due to an underlying medical condition. 3. A physical examination is needed to determine the etiology of the client’s problem. 4. The client’s anxiolytic dosage needs to be increased.
answer

. A physical examination is needed to determine the etiology of the client’s problem
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A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive compulsive disorder. Which behavioral symptom would the nurse expect to assess? 1. The client uses excessive hand washing to relieve anxiety. 2. The client rates anxiety at 8/10. 3. The client uses breathing techniques to decrease anxiety. 4. The client exhibits diaphoresis and tachycardia.
answer

The client uses excessive hand washing to relieve anxiety.
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A client experiencing a panic attack would display which physical symptom? 1. Fear of dying. 2. Sweating and palpitations. 3. Depersonalization. 4. Restlessness and pacing.
answer

Sweating and palpitations.
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In which situation would the nurse suspect a medical diagnosis of social phobia? 1. A client abuses marijuana daily and avoids social situations because of fear of humiliation. 2. An 8-year-old child isolates from adults because of fear of embarrassment, but has good peer relationships in school. 3. A client diagnosed with Parkinson’s disease avoids social situations because of embarrassment regarding tremors and drooling. 4. A college student avoids taking classes that include an oral presentation because of fear of being scrutinized by others.
answer

A college student avoids taking classes that include an oral presentation because of fear of being scrutinized by others.
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Which of the following assessment data would support the disorder of acrophobia? 1. A client is fearful of basements because of encountering spiders. 2. A client refuses to go to Europe because of fear of flying. 3. A client is unable to commit to marriage after a 10-year engagement. 4. A client refuses to leave home during stormy weather.
answer

client refuses to go to Europe because of fear of flying.
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A newly admitted client is diagnosed with posttraumatic stress disorder. Which behavioral symptom would the nurse expect to assess? 1. Recurrent, distressing flashbacks. 2. Intense fear, helplessness, and horror. 3. Diminished participation in significant activities. 4. Detachment or estrangement from others.
answer

Diminished participation in significant activities.
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When treating individuals with posttraumatic stress disorder, which variables are included in the recovery environment? 1. Degree of ego strength. 2. Availability of social supports. 3. Severity and duration of the stressor. 4. Amount of control over reoccurrenc
answer

Availability of social supports.
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Which of the following would the nurse expect to assess in a client diagnosed with posttraumatic stress disorder? Select all that apply. 1. Dissociative events. 2. Intense fear and helplessness. 3. Excessive attachment and dependence toward others. 4. Full range of affect. 5. Avoidance of activities that are associated with the trauma.
answer

Dissociative events. Intense fear and helplessness. Avoidance of activities that are associated with the trauma.
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A newly admitted client diagnosed with posttraumatic stress disorder is exhibiting recurrent flashbacks, nightmares, sleep deprivation, and isolation from others. Which nursing diagnosis takes priority? 1. Posttrauma syndrome R /T a distressing event AEB flashbacks and nightmares. 2. Social isolation R /T anxiety AEB isolating because of fear of flashbacks. 3. Ineffective coping R /T flashbacks AEB alcohol abuse and dependence. 4. Risk for injury R /T exhaustion because of sustained levels of anxiety
answer

Risk for injury R /T exhaustion because of sustained levels of anxiety
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A client leaving home for the first time in a year arrives on the psychiatric in-patient unit wearing a surgical mask and white gloves and crying, “The germs in here are going to kill me.” Which nursing diagnosis addresses this client’s problem? 1. Social isolation R /T fear of germs AEB continually refusing to leave the home. 2. Fear of germs R /T obsessive-compulsive disorder, resulting in dysfunctional isolation. 3. Ineffective coping AEB dysfunctional isolation R /T unrealistic fear of germs. 4. Anxiety R /T the inability to leave home, resulting in dysfunctional fear of germs.
answer

Social isolation R /T fear of germs AEB continually refusing to leave the home.
question

A client seen in an out-patient clinic for ongoing management of panic attacks states, “I have to make myself come to these appointments. It is hard because I don’t know when an attack will occur.” Which nursing diagnosis takes priority? 1. Ineffective breathing patterns R /T hyperventilation. 2. Impaired spontaneous ventilation R /T panic levels of anxiety. 3. Social isolation R /T fear of spontaneous panic attacks. 4. Knowledge deficit R /T triggers for panic attacks
answer

Social isolation R /T fear of spontaneous panic attacks.
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A client newly admitted to an in-patient psychiatric unit is diagnosed with obsessive compulsive disorder. Which correctly stated nursing diagnosis takes priority? 1. Anxiety R /T obsessive thoughts AEB ritualistic behaviors. 2. Powerlessness R /T ritualistic behaviors AEB statements of lack of control. 3. Fear R /T a traumatic event AEB stimulus avoidance. 4. Social isolation R /T increased levels of anxiety AEB not attending groups
answer

Anxiety R /T obsessive thoughts AEB ritualistic behaviors.
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During an assessment, a client diagnosed with generalized anxiety disorder rates anxiety as 9/10 and states, “I have thought about suicide because nothing ever seems to work out for me.” Based on this information, which nursing diagnosis takes priority? 1. Hopelessness R /T anxiety AEB client’s stating, “Nothing ever seems to work out.” 2. Ineffective coping R /T rating anxiety as 9/10 AEB thoughts of suicide. 3. Anxiety R /T thoughts about work AEB rates anxiety 9/10. 4. Risk for suicide R /T expressing thoughts of suicide
answer

Risk for suicide R /T expressing thoughts of suicide
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A hospitalized client diagnosed with posttraumatic stress disorder has a nursing diagnosis of ineffective coping R /T history of rape AEB abusing alcohol. Which is the expected short-term outcome for this client problem? 1. The client will recognize triggers that precipitate alcohol abuse by day 2. 2. The client will attend follow-up weekly therapy sessions after discharge. 3. The client will refrain from self-blame regarding the rape by day 2. 4. The client will be free from injury to self throughout the shift.
answer

. The client will recognize triggers that precipitate alcohol abuse by day 2.
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A newly admitted client diagnosed with social phobia has a nursing diagnosis of social isolation R/T fear of ridicule. Which outcome is appropriate for this client? 1. The client will participate in two group activities by day 4. 2. The client will use relaxation techniques to decrease anxiety. 3. The client will verbalize one positive attribute about self by discharge. 4. The client will request buspirone (BuSpar) PRN to attend group by day 2.
answer

The client will participate in two group activities by day 4.
question

When a client experiences a panic attack, which outcome takes priority? 1. The client will remain safe throughout the duration of the panic attack. 2. The client will verbalize an anxiety level less than 2/10. 3. The client will use learned coping mechanisms to decrease anxiety. 4. The client will verbalize the positive effects of exercise by day 2
answer

The client will remain safe throughout the duration of the panic attack.
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The nurse has received evening report. Which client would the nurse need to assess first? 1. A newly admitted client with a history of panic attacks. 2. A client who slept 2 to 3 hours last night because of flashbacks. 3. A client pacing the halls and stating that his anxiety is an 8/10. 4. A client diagnosed with generalized anxiety disorder awaiting discharge.
answer

A client pacing the halls and stating that his anxiety is an 8/10. the first one”HISTORY of panic attacks.”
question

A client was admitted to an in-patient psychiatric unit 4 days ago for the treatment of obsessive-compulsive disorder. Which outcome takes priority for this client at this time? 1. The client will use a thought-stopping technique to eliminate obsessive/compulsive behaviors. 2. The client will stop obsessive and/or compulsive behaviors. 3. The client will seek assistance from the staff to decrease obsessive or compulsive behaviors. 4. The client will use one relaxation technique to decrease obsessive or compulsive behaviors.
answer

The client will use one relaxation technique to decrease obsessive or compulsive behaviors.
question

A client diagnosed with generalized anxiety disorder has a nursing diagnosis of panic anxiety R/T altered perceptions. Which of the following short-term outcomes is most appropriate for this client? 1. The client will be able to intervene before reaching panic levels of anxiety by discharge. 2. The client will verbalize decreased levels of anxiety by day 2. 3. The client will take control of life situations by using problem-solving methods effectively. 4. The client will voluntarily participate in group therapy activities by discharge
answer

The client will be able to intervene before reaching panic levels of anxiety by discharge.
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A client on an in-patient psychiatric unit is experiencing a flashback. Which intervention takes priority? 1. Maintain and reassure the client of his or her safety and security. 2. Encourage the client to express feelings. 3. Decrease extraneous external stimuli. 4. Use a nonjudgmental and matter-of-fact approach.
answer

Maintain and reassure the client of his or her safety and security.
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A client diagnosed with panic attacks is being admitted for the fifth time in 1 year because of hopelessness and helplessness. Which precaution would the nurse plan to implement? 1. Elopement precautions. 2. Suicide precautions. 3. Homicide precautions. 4. Fall precautions.
answer

Suicide precautions.
question

A client diagnosed with obsessive-compulsive disorder has been hospitalized for the last 4 days. Which intervention would be a priority at this time? 1. Notify the client of the expected limitations on compulsive behaviors. 2. Reinforce the use of learned relaxation techniques. 3. Allow the client the time needed to complete the compulsive behaviors. 4. Say “stop” to the client as a thought-stopping technique.
answer

Reinforce the use of learned relaxation techniques.
question

The nurse on the in-patient psychiatric unit should include which of the following interventions when working with a newly admitted client diagnosed with obsessive compulsive disorder? Select all that apply. 1. Assess previously used coping mechanisms and their effects on anxiety. 2. Allow time for the client to complete compulsions. 3. With the client’s input, set limits on ritualistic behaviors. 4. Present the reality of the impact the compulsions have on the client’s life. 5. Discuss client feelings surrounding the obsessions and compulsions
answer

1. Assess previously used coping mechanisms and their effects on anxiety. 2. Allow time for the client to complete compulsions. Discuss client feelings surrounding the obsessions and compulsions
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A client diagnosed with generalized anxiety disorder complains of feeling out of control and states, “I just can’t do this anymore.” Which nursing action takes priority at this time? 1. Ask the client, “Are you thinking about harming yourself?” 2. Remove all potentially harmful objects from the milieu. 3. Place the client on a one-to-one observation status. 4. Encourage the client to verbalize feelings during the next group
answer

Ask the client, “Are you thinking about harming yourself?”
question

During an intake assessment, a client diagnosed with generalized anxiety disorder rates mood at 3/10, rates anxiety at 8/10, and states, “I’m thinking about suicide.” Which nursing intervention takes priority? 1. Teach the client relaxation techniques. 2. Ask the client, “Do you have a plan to commit suicide?” 3. Call the physician to obtain a PRN order for an anxiolytic medication. 4. Encourage the client to participate in group activities.
answer

Ask the client, “Do you have a plan to commit suicide?”
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A client diagnosed with posttraumatic stress disorder has a nursing diagnosis of disturbed sleep patterns R /T nightmares. Which evaluation would indicate that the stated nursing diagnosis was resolved? 1. The client expresses feelings about the nightmares during group. 2. The client asks for PRN trazodone (Desyrel) before bed to fall asleep. 3. The client states that the client feels rested when awakening and denies nightmares. 4. The client avoids napping during the day to help enhance sleep.
answer

The client states that the client feels rested when awakening and denies nightmares.
question

the nurse teaches an anxious client diagnosed with posttraumatic stress disorder a breathing technique. Which action by the client would indicate that the teaching was successful? 1. The client eliminates anxiety by using the breathing technique. 2. The client performs activities of daily living independently by discharge. 3. The client recognizes signs and symptoms of escalating anxiety. 4. The client maintains a 3/10 anxiety level without medications.
answer

The client maintains a 3/10 anxiety level without medications.
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55. The nurse is using a cognitive intervention to decrease anxiety during a client’s panic attack. Which statement by the client would indicate that the intervention has been successful? 1. “I reminded myself that the panic attack would end soon, and it helped.” 2. “I paced the halls until I felt my anxiety was under control.” 3. “I felt my anxiety increase, so I took lorazepam (Ativan) to decrease it.” 4. “Thank you for staying with me. It helped to know staff was there.
answer

“I reminded myself that the panic attack would end soon, and it helped.”
question

Which of the following medications can be used to treat clients with anxiety disorders? Select all that apply. 1. Clonidine hydrochloride (Catapres). 2. Fluvoxamine maleate (Luvox). 3. Buspirone (BuSpar). 4. Alprazolam (Xanax). 5. Haloperidol (Haldol).
answer

1. Clonidine hydrochloride (Catapres). 2. Fluvoxamine maleate (Luvox). 3. Buspirone (BuSpar). 4. Alprazolam (Xanax).
question

57. A client is prescribed alprazolam (Xanax) 2 mg bid and 1.5 mg q6h PRN for agitation. The maximum daily dose of alprazolam is 10 mg/d. The client can receive _____ PRN doses of alprazolam within a 24-hour period.
answer

question

58. Which teaching need is important when a client is newly prescribed buspirone (BuSpar) 5 mg tid? 1. Encourage the client to avoid drinking alcohol while taking this medication because of the additive central nervous system depressant effects. 2. Encourage the client to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks. 3. Encourage the client to monitor for signs and symptoms of anxiety to determine need for additional buspirone (BuSpar) PRN. 4. Encourage the client to be compliant with monthly lab tests to monitor for medication toxicity.
answer

Encourage the client to take the medication continually as prescribed because onset of action is delayed 2 to 3 weeks.
question

Which nursing diagnosis supports the psychoanalytic theory of development of major depressive disorder? 1. Social isolation R / T self-directed anger. 2. Low self-esteem R / T learned helplessness. 3. Risk for suicide R / T neurochemical imbalances. 4. Imbalanced nutrition less than body requirements R / T weakness.
answer

Social isolation R / T self-directed anger.
question

2. Which client statement is evidence of the etiology of major depressive disorder from a GENETIC perspective? 1. “My maternal grandmother was diagnosed with bipolar affective disorder.” 2. “My mood is a 7 out of 10, and I won’t harm myself or others.” 3. “I am so angry that my father left our family when I was 6.” 4. “I just can’t do anything right. I am worthless.”
answer

“My maternal grandmother was diagnosed with bipolar affective disorder.”
question

3. During an intake assessment, which client statement is evidence of the etiology of major depressive disorder from an object-loss theory perspective? 1. “I am so angry all the time and seem to take it out on myself.” 2. “My grandmother and great-grandfather also had depression.” 3. “I just don’t think my life is ever going to get better. I can’t do anything right.” 4. “I don’t know about my biological family; I was in foster care as an infant.”
answer

“I don’t know about my biological family; I was in foster care as an infant.”
question

4. Which statement about the development of bipolar disorder is from a biochemical perspective? 1. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. 2. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium. 3. Magnetic resonance imaging studies have revealed enlarged third ventricles, subcortical white matter, and periventricular hyperintensity in individuals diagnosed with bipolar disorder. 4. Twin studies have indicated a concordance rate among monozygotic twins of 60% to 80%.
answer

In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium.
question

5. Which statement describes a major difference between a client diagnosed with major depressive disorder and a client diagnosed with dysthymic disorder? 1. A client diagnosed with dysthymic disorder is at higher risk for suicide. 2. A client diagnosed with dysthymic disorder may experience psychotic features. 3. A client diagnosed with dysthymic disorder experiences excessive guilt. 4. A client diagnosed with dysthymic disorder has symptoms for at least 2 years.
answer

A client diagnosed with dysthymic disorder has symptoms for at least 2 years.
question

6. A client expresses frustration and hostility toward the nursing staff regarding the lack of care his or her recently deceased parent received. According to Kubler-Ross, which stage of grief is this client experiencing? 1. Anger. 2. Disequilibrium. 3. Developing awareness. 4. Bargaining.
answer

1. Anger.
question

8. Which charting entry most accurately documents a client’s mood? 1. “The client expresses an elevation in mood.” 2. “The client appears euthymic and is interacting with others.” 3. “The client isolates self and is tearful most of the day.” 4. “The client rates mood at a 2 out of 10.”
answer

“The client rates mood at a 2 out of 10.”
question

9. Which client is at highest risk for the diagnosis of major depressive disorder? 1. A 24-year-old married woman. 2. A 64-year-old single woman. 3. A 30-year-old single man. 4. A 70-year-old married man.
answer

A 24-year-old married woman.
question

10. A client is admitted to an in-patient psychiatric unit with a diagnosis of major depressive disorder. Which of the following data would the nurse expect to assess? Select all that apply. 1. Loss of interest in almost all activities and anhedonia. 2. A change of more than 5% of body weight in 1 month. 3. Fluctuation between increased energy and loss of energy. 4. Psychomotor retardation or agitation. 5. Insomnia or hypersomnia.
answer

1. Loss of interest in almost all activities and anhedonia. 2. A change of more than 5% of body weight in 1 month. 4. Psychomotor retardation or agitation. 5. Insomnia or hypersomnia.
question

11. A client is exhibiting behavioral symptoms of depression. Which charting entry would appropriately document these symptoms? 1. “Rates mood as 4/10.” 2. “Expresses thoughts of poor self-esteem during group.” 3. “Became irritable and agitated on waking.” 4. “Rates anxiety as 2/10 after receiving lorazepam (Ativan).”
answer

“Became irritable and agitated on waking.”
question

12. Which symptom is an example of physiological alterations exhibited by clients diagnosed with moderate depression? 1. Decreased libido. 2. Difficulty concentrating. 3. Slumped posture. 4. Helplessness.
answer

Decreased libido.
question

13. Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression? 1. Apathy. 2. Somatic delusion. 3. Difficulty falling asleep. 4. Social isolation.
answer

question

14. Major depressive disorder would be most difficult to detect in which of the following clients? 1. A 5-year-old girl. 2. A 13-year-old boy. 3. A 25-year-old woman. 4. A 75-year-old man.
answer

A 13-year-old boy.
question

15. Which is the key to understanding if a child or adolescent is experiencing an underlying depressive disorder? 1. Irritability with authority. 2. Being uninterested in school. 3. A change in behaviors over a 2-week period. 4. Feeling insecure at a social gathering.
answer

A change in behaviors over a 2-week period.
question

16. The nurse in the emergency department is assessing a client suspected of being suicidal. following assessment questions, the most critical question? ___ “Are you currently thinking about suicide?” ___ “Do you have a gun in your possession?” ___ “Do you have a plan to commit suicide?” ___ “Do you live alone? Do you have local friends or family?”
answer

“Are you currently thinking about suicide?”
question

17. Which nursing charting entry is documentation of a behavioral symptom of mania? 1. “Thoughts fragmented, flight of ideas noted.” 2. “Mood euphoric and expansive. Rates mood a 10/10.” 3. “Pacing halls throughout the day. Exhibits poor impulse control.” 4. “Easily distracted, unable to focus on goals.”
answer

“Pacing halls throughout the day. Exhibits poor impulse control.
question

18. A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first? 1. A client on one-to-one status because of active suicidal ideations. 2. A client pacing the hall and experiencing irritability and flight of ideas. 3. A client diagnosed with hypomania monopolizing time in the milieu. 4. A client with a history of mania who is to be discharged in the morning.
answer

2. A client pacing the hall and experiencing irritability and flight of ideas.
question

19. A nurse is planning to teach about appropriate coping skills. The nurse would expect which client to be at the highest level of readiness to participate in this instruction? 1. A newly admitted client with an anxiety level of 8/10 and racing thoughts. 2. A client admitted 6 days ago for a manic episode refusing to take medications. 3. A newly admitted client experiencing suicidal ideations with a plan to overdose. 4. A client admitted 6 days ago for suicidal ideations following a depressive episode.
answer

A client admitted 6 days ago for suicidal ideations following a depressive episode. 6 days ago, so he stabilized in 6 days and ready to particupate in teaching.
question

20. A newly admitted client has been diagnosed with major depressive disorder. Which nursing diagnosis takes priority? 1. Social isolation R / T poor mood AEB refusing visits from family. 2. Self-care deficit R / T hopelessness AEB not taking a bath for 2 weeks. 3. Anxiety R / T hospitalization AEB anxiety rating of an 8/10. 4. Risk for self-directed violence R / T depressed mood.
answer

Risk for self-directed violence R / T depressed mood.
question

21. A client’s outcome states, “The client will make a plan to take control of one life situation by discharge.” Which nursing diagnosis documents the client’s problem that this outcome addresses? 1. Impaired social interaction. 2. Powerlessness. 3. Knowledge deficit. 4. Dysfunctional grieving.
answer

Powerlessness.
question

2. Which nursing diagnosis takes priority for a client immediately after electroconvulsive therapy (ECT)? 1. Risk for injury R / T altered mental status. 2. Impaired social interaction R / T confusion. 3. Activity intolerance R / T weakness. 4. Chronic confusion R / T side effect of ECT.
answer

Risk for injury R / T altered mental status.
question

23. A client diagnosed with major depressive disorder has been newly admitted to an inpatient psychiatric unit. The client has a history of two suicide attempts by hanging. Which nursing diagnosis takes priority? 1. Risk for violence directed at others R / T anger turned outward. 2. Social isolation R / T depressed mood. 3. Risk for suicide R / T history of attempts. 4. Hopelessness R / T multiple suicide attempts.
answer

Risk for suicide R / T history of attempts.
question

4. A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority? 1. Altered thought processes R / T biochemical alterations. 2. Social isolation R / T grandiosity. 3. Disturbed sleep patterns R / T agitation. 4. Risk for violence: self-directed R / T depressive symptoms.
answer

Disturbed sleep patterns R / T agitation
question

25. A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is a priority at this time? 1. Risk for violence: other-directed R / T poor impulse control. 2. Altered thought process R / T hallucinations. 3. Social isolation R / T manic excitement. 4. Low self-esteem R / T guilt about promiscuity. Nursing Process—Planni
answer

Risk for violence: other-directed R / T poor impulse control.
question

26. A client admitted with major depressive disorder has a nursing diagnosis of ineffective sleep pattern R / T aches and pains. Which is an appropriate short-term outcome for this client? 1. The client will express feeling rested on awakening. 2. The client will rate pain level at or below a 4/10. 3. The client will sleep 6 to 8 hours at night by day 5. 4. The client will maintain a steady sleep pattern while hospitalized.
answer

3. The client will sleep 6 to 8 hours at night by day 5.
question

27. Which client would the charge nurse assign to an agency nurse working on the inpatient psychiatric unit for the first time? 1. A client experiencing passive suicidal ideations with a past history of an attempt. 2. A client rating mood as 3/10 and attending but not participating in group therapy. 3. A client lying in bed all day long in a fetal position and refusing all meals. 4. A client admitted for the first time with a diagnosis of major depression.
answer

A client rating mood as 3/10 and attending but not participating in group therapy.
question

28. A client has a nursing diagnosis of risk for suicide R / T a past suicide attempt. Which outcome, based on this diagnosis, would the nurse prioritize? 1. The client will remain free from injury throughout hospitalization. 2. The client will set one realistic goal related to relationships by day 3. 3. The client will verbalize one positive attribute about self by day 4. 4. The client will be easily redirected when discussion about suicide occurs by day 5.
answer

The client will remain free from injury throughout hospitalization.
question

29. A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R / T biochemical alterations. Based on this diagnosis, which outcome would be appropriate? 1. The client will not experience injury throughout the shift. 2. The client will interact appropriately with others by day 3. 3. The client will be compliant with prescribed medications. 4. The client will distinguish reality from delusions by day 6.
answer

The client will distinguish reality from delusions by day 6.
question

30. The nurse is reviewing expected outcomes for a client diagnosed with bipolar I disorder. Number the outcomes presented in the order in which the nurse would address them. ___ The client exhibits no evidence of physical injury. ___ The client eats 70% of all finger foods offered. ___ The client is able to access available out-patient resources. ___ The client accepts responsibility for own behaviors.
answer

The client exhibits no evidence of physical injury The client eats 70% of all finger foods offered. the client accepts responsibility for own behaviors The client is able to access available out-patient resources..
question

31. A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R / T egocentrism. Which short-term outcome is an appropriate expectation for this client problem? 1. The client will have an appropriate one-on-one interaction with a peer by day 4. 2. The client will exchange personal information with peers at lunchtime. 3. The client will verbalize the desire to interact with peers by day 2. 4. The client will initiate an appropriate social relationship with a peer.
answer

The client will have an appropriate one-on-one interaction with a peer by day 4.
question

A suicidal Jewish-American client is admitted to an in-patient psychiatric unit 2 days after the death of a parent. Which intervention must the nurse include in the care of this client? 1. Allow the client time to mourn the loss during this time of shiva. 2. To distract the client from the loss, encourage participation in unit groups. 3. Teach the client alternative coping skills to deal with grief. 4. Discuss positive aspects the client has in his or her life to build on strengths.
answer

1. Allow the client time to mourn the loss during this time of shiva.
question

33. A client denying suicidal ideations comes into the emergency department complaining about insomnia, irritability, anorexia, and depressed mood. Which intervention would the nurse implement first? 1. Request a psychiatric consultation. 2. Complete a thorough physical assessment including lab tests. 3. Remove all hazardous materials from the environment. 4. Place the client on a one-to-one observation.
answer

Complete a thorough physical assessment including lab tests.
question

34. A client diagnosed with major depressive disorder has a nursing diagnosis of low selfesteem R / T negative view of self. Which cognitive intervention by the nurse would be appropriate to deal with this client’s problem? 1. Promote attendance in group therapy to assist client to socialize. 2. Teach assertiveness skills by role-playing situations. 3. Encourage the client to journal to uncover underlying feelings. 4. Focus on strengths and accomplishments to minimize failures.
answer

Focus on strengths and accomplishments to minimize failures.
question

35. A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship? 1. Sit with the client and offer self frequently. 2. Notify the client of group therapy schedule. 3. Introduce the client to others on the unit. 4. Help the client to identify stressors of life that precipitate life crises.
answer

Sit with the client and offer self frequently.
question

36. A client diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize? 1. Empathize with the client about fears regarding ECT. 2. Monitor for any cardiac alterations to avoid possible negative outcomes. 3. Discuss with the client and family expected short-term memory loss. 4. Inform the client that injury related to induced seizure commonly occurs.
answer

3. Discuss with the client and family expected short-term memory loss.
question

37. Which intervention takes priority when working with newly admitted clients experiencing suicidal ideations? 1. Monitor the client at close, but irregular, intervals. 2. Encourage the client to participate in group therapy. 3. Enlist friends and family to assist the client to remain safe after discharge. 4. Remind the client that it takes 4 to 6 weeks for antidepressants to be fully effective.
answer

Monitor the client at close, but irregular, intervals.
question

38. A client notifies a staff member of current suicidal ideations. Which intervention by the nurse would take priority? 1. Place the client on a one-to-one observation. 2. Determine if the client has a specific plan to commit suicide. 3. Assess for past history of suicide attempts. 4. Notify all staff members and place the client on suicide precautions.
answer

2. Determine if the client has a specific plan to commit suicide.
question

39. A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse’s priority intervention? 1. Place the client on a one-to-one to avoid injury. 2. Ask the physician for a psychiatric consultation. 3. Assess vital signs, and complete physical assessment. 4. Reinforce relaxation techniques to decrease anxiety.
answer

Assess vital signs, and complete physical assessment.
question

40. A client experiencing mania states, “Everything I do is great.” Using a cognitive approach, which nursing response would be most appropriate? 1. “Is there a time in your life when things didn’t go as planned?” 2. “Everything you do is great.” 3. “What are some other things you do well?” 4. “Let’s talk about the feelings you have about your childhood.”
answer

Is there a time in your life when things didn’t go as planned?”
question

41. A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client’s a nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client? 1. Chicken fingers and French fries. 2. Grilled chicken and a baked potato. 3. Spaghetti and meatballs. 4. Chili and crackers.
answer

Chicken fingers and French fries
question

42. A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation? 1. Join the milieu to assess the appropriateness of the laughter. 2. Redirect clients in the milieu to structured social activities, such as cards. 3. Privately discuss with the client the inappropriateness of provocative dress during hospitalization. 4. Administer PRN antianxiety medication to calm the client.
answer

Privately discuss with the client the inappropriateness of provocative dress during hospitalization.
question

43. A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? 1. Calmly redirect and remove the client from the milieu. 2. Administer prescribed PRN intramuscular injection for agitation. 3. Notify the client to lower voice. 4. Obtain an order for seclusion to help decrease external stimuli.
answer

. Calmly redirect and remove the client from the milieu.
question

44. A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R / T extreme hyperactivity. Which nursing intervention is appropriate? 1. Place the client in a room with another client experiencing similar symptoms. 2. Use PRN antipsychotic medications as ordered by the physician. 3. Discuss consequences of the client’s behaviors with the client daily. 4. Reinforce previously learned coping skills to decrease agitation.
answer

Reinforce previously learned coping skills to decrease agitation.
question

45. A client diagnosed with bipolar I disorder experienced an acute manic episode and was admitted to the in-patient psychiatric unit. The client is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply. 1. Financial and legal assistance. 2. Crisis hotline. 3. Individual psychotherapy. 4. Support groups. 5. Family education groups
answer

1. Financial and legal assistance. 2. Crisis hotline. 3. Individual psychotherapy. 4. Support groups. 5. Family education groups
question

A nursing student is studying major depressive disorder. Which student statement indicates that learning has occurred? 1. “1% of the population is affected by depression yearly.” 2. “2% to 5% of women experience depression during their lifetimes.” 3. “1% to 3% of men become clinically depressed.” 4. “Major depression is a leading cause of disability in the United States.
answer

“Major depression is a leading cause of disability in the United States.