Depression
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.
b. You're wearing a new shirt.
c.I like the shirt you are wearing.
d. You must be feeling better today
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.
A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident?
a. increased muscle tension and anxiety
b. vegetative signs and poor grooming
c. poor judgement and hyperactivity
d. cognitive deficits and paranoia
C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania.
What is the biggest risk fact for cognition impairment?
Advanced age
An older adult patient takes multiple medications daily. Over 2 days, the patient developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. These findings are most characteristic of:
a. delirium
b. dementia
c. amnestic syndrome
d. Alzheimer's disease
A
Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.
A patient with fluctuating levels of awareness, confusion, and disturbed orientation shouts, Bugs are crawling on my legs. Get them off! Which problem is the patient experiencing?
a. aphasia
b. dystonia
c. tactile hallucinations
d. mnemonic disturbance
C
The patient feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium.
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
b. relaxation training
c. desensitization therapy
d. use of complementary therapy
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 patients support system.
A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, Do you like my scarves? Here; they are my gift to you. How should the nurse document the patients mood?
a. euphoric
b. irritable
c. suspicious
d. confident
A
The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patients mood. Suspiciousness is not evident.
Aphagia is what?
Agnosia is what?
Apraxia is what?
difficulty with language (in and out)
difficulty recognizing objects or people
inability to perform purposeful movements or manipulate objects
What is the priority nursing diagnosis for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations?
a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment
b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks
c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations
d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations
A
The physical safety of the patient is of highest priority among the diagnoses given. Many opportunities for injury exist when a patient misperceives the environment as distorted, threatening, or harmful or when the patient exercises poor judgment or when the patients sensorium is clouded. The other diagnoses may be concerns, but are lower priorities.
What is the priority intervention for a patient diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations?
a. Distraction using sensory stimulation
b. Careful observation and supervision
c. Avoidance of physical contact
d. Activation of the bed alarm
B
Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the patient will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the patients safety.
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 observations 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
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.
A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority?
a. risk for injury
b. ineffective coping
c. impaired social interaction
d. ineffective therapeutic regimen management
A
Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patients physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.
Nursing interventions for a student with ADHD unable to remain on task in class...
clear desk except for classwork and pencil
seat student near the teacher
maintain structured classroom
allow student to stand at desk
consistency
A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient?
a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.
b. Maintain soft lighting day and night. Keep a radio on low volume continuously.
c. Light the room brightly day and night. Awaken the patient hourly to assess mental status
d. Keep the patient by the nurses desk while awake. Provide rest periods in a room with a television on
A
A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.
Consider these health problems: Lewy body disease, frontal-temporal lobar degeneration, and Huntingtons disease. Which term unifies these problems?
a. cyclothymia
b. dementia
c. delirium
d. amnesia
All health problems listed are a form of dementia
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
b. anhedonia
c. euphoria
d. anergia
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
The exact cause of bipolar disorder has not been determined; however, for most patients:
a. several factors; including genetics
b. brain structures were altered by stress early in life
c. excess sensitivity in dopamine receptors may trigger episodes
d. inadequate norepinephrine reuptake disturbs circadian rhythms
A
The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.
Nursing interventions for child with ADHD with impaired social interaction
positive reinforcement
encourage structured play dates
encourage involvement in after school activities
An older adult was stopped by police for driving through a red light. When asked for a drivers license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident?
a. aphasia
b. apraxia
c. agnosia
d. anhedonia
C
Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.
A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment?
a. Assist the patient to perform simple tasks by giving step-by-step directions.
b. Reduce frustration by performing activities of daily living for the patient.
c. Stimulate intellectual function by discussing new topics with the patient.
d. Read one story from the newspaper to the patient every day
A
Patients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the patient is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the patient. Patients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.
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
b. over-involvement
c. interest and pleasure
d. ineffectiveness and frustration
D
Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patients 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 patients resistance. Guilt and despair might be seen when the nurse experiences the patients feelings because of empathy. Interest is possible, but not the most likely result.
A patient diagnosed with bipolar disorder commands other patients, Get me a book. Take this stuff out of here, and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select?
a. distraction: lets go to the dining room for a snack
b. humor: how much are you paying servants these days?
c. limit setting: you must stop ordering others around
d. honest feedback: your controlling your behavior is annoying others
A
The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.
Ideomotor apraxia is classified as a deficit in which cognitive area?
a. Memory
b. language
c. thought process d. visuospatial
D
Ideomotor apraxia is an abnormality affecting the visuospatial cognitive area. Apraxia is the inability to perform purposeful movements or manipulate objects despite intact sensory and motor abilities. Ideomotor apraxia is a specific type of apraxia in which there is an inability to translate an idea into action.
Consider these diagnostic findings: apolipoprotein E (apoE) malfunction, neurofibrillary tangles, neuronal degeneration in the hippocampus, and brain atrophy. Which health problem corresponds to these diagnostic findings?
a. Huntingtons disease
b. Alzheimers disease
c. Parkinsons disease
d. Vascular dementia
B
All of the options relate to dementias; however, the pathophysiological phenomena described apply to Alzheimers disease. Parkinsons disease is associated with dopamine dysregulation. Huntingtons disease is genetic. Vascular dementia is the consequence of circulatory changes
During morning care, a nurse asks a patient diagnosed with dementia, How was your night? The patient replies, It was lovely. I went out to dinner and a movie with my friend. Which term applies to the patients response?
a. sundown syndrome
b. confabulation
c. perseveration
d. delirium
B
Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The patients response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.