Mental Health 1
The diagnosis of major depressive disorder requires the presence of at least five symptoms, including a depressed mood or loss of interest or pleasure in almost all activities, lasting for at least _____ weeks.
Two
Rationale:
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for major depressive disorder require that symptoms persist for at least two weeks and cause significant distress or impairment in functioning.
_____ disorder is characterized by excessive, uncontrollable worry about a variety of topics, events, or activities, occurring more days than not for at least six months.
Generalized anxiety
Rationale:
Generalized anxiety disorder (GAD) is defined by persistent and excessive worry, affecting the individual’s ability to concentrate and carry out daily activities. It must occur for at least six months for diagnosis.
The nurse is assessing a patient's postoperative wound and observes clear, watery drainage. How should the nurse document this finding?
A. Purulent
B. Serous
C. Sanguineous
D. Serosanguineous
B. Serous
Rationale: Serous drainage is clear and watery, often seen in the early stages of wound healing.
Which instruction should the nurse provide to a patient who is beginning a 24-hour urine collection?
A. "Start the collection by saving your first urine sample."
B. "All urine should be kept at room temperature."
C. "Discard your first urine sample, then begin the collection."
D. "Place each urine sample in a separate container."
C. "Discard your first urine sample, then begin the collection."
Rationale: The patient should discard the first urine sample to mark the beginning of the 24-hour period, then collect all urine during that timeframe.
A common non-pharmacological approach to relieving constipation involves increasing dietary ________, which can help increase stool bulk and promote regular bowel movements.
Fiber
Rationale:
Increasing fiber intake is a key non-pharmacological treatment for constipation. Fiber helps increase stool bulk and stimulates the bowel, improving bowel regularity. It is generally recommended alongside adequate hydration to prevent and treat constipation.
A common class of medications used to treat depression and anxiety is selective serotonin reuptake inhibitors (SSRIs), such as _____, which increase serotonin levels in the brain.
Fluoxetine
Rationale:
Fluoxetine (Prozac) is a commonly prescribed SSRI that increases serotonin levels in the brain. It is used to treat conditions like major depression, generalized anxiety disorder, and obsessive-compulsive disorder.
_____ personality disorder is characterized by a pattern of disregard for the rights of others, impulsivity, and lack of remorse for harmful behavior.
Antisocial
Rationale:
Antisocial personality disorder is marked by a consistent pattern of violating the rights of others, often through deceit, manipulation, or impulsive actions. These individuals often show a lack of empathy or remorse for their actions.
A nurse is caring for a patient with a pressure injury on the sacrum. The wound has full-thickness skin loss, visible adipose tissue, and slough. No bone, tendon, or muscle is exposed. Which stage should the nurse assign to this pressure injury?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
C. Stage 3
Rationale: A Stage 3 pressure injury presents with full-thickness skin loss and visible fat but no exposed bone, tendon, or muscle.
A nurse is caring for a patient receiving chemotherapy. The patient's white blood cell (WBC) count is 2,000/mm³. Which intervention should the nurse implement?
A. Encourage fresh fruits and vegetables
B. Administer an antipyretic for fever above 100°F
C. Implement protective isolation precautions
D. Encourage the patient to perform oral hygiene twice daily
C. Implement protective isolation precautions
Rationale: A WBC count of 2,000/mm³ indicates neutropenia, requiring protective isolation to reduce the risk of infection.
Which of the following are common symptoms of acute gastroenteritis? (Select all that apply)
A) Vomiting
B) Diarrhea
C) Abdominal cramping
D) Bloody stools
E) High fever
A) Vomiting
B) Diarrhea
C) Abdominal cramping
Rationale:
Common symptoms of acute gastroenteritis include vomiting, diarrhea, and abdominal cramping due to viral or bacterial infection. Bloody stools may occur with more severe infections but are not typical of all cases. A high fever can be present but is not universal.
Mr. Alan Foster, a 25-year-old male, has been diagnosed with obsessive-compulsive disorder (OCD). He has intrusive thoughts that lead to compulsive hand-washing rituals, which have significantly impacted his daily functioning.
Question: Which of the following interventions is most appropriate for Mr. Foster's OCD?
A) Encourage Mr. Foster to gradually reduce the frequency of his hand-washing rituals.
B) Allow Mr. Foster to complete his rituals without interference to prevent anxiety.
C) Use a cognitive-behavioral therapy (CBT) approach to challenge the intrusive thoughts.
D) Encourage Mr. Foster to focus on avoiding the situations that trigger his compulsions.
A) Encourage Mr. Foster to gradually reduce the frequency of his hand-washing rituals.
Rationale: (A) Encouraging gradual reduction in hand-washing rituals is a form of exposure and response prevention, which is effective in treating OCD. CBT (C) can also be helpful but gradual reduction is often the first step. Allowing the rituals to continue (B) and avoiding triggers (D) can reinforce the compulsions.
Ms. Carrie Thomas, a 29-year-old female, is diagnosed with anorexia nervosa. She has lost 20 pounds in the last month and is severely restricting her food intake.
Question: Which of the following is the most appropriate nursing intervention for Ms. Thomas?
A) Encourage Ms. Thomas to eat small, frequent meals to gradually increase her caloric intake.
B) Allow Ms. Thomas to make all decisions about her food intake to promote autonomy.
C) Restrict Ms. Thomas' access to a mirror to prevent self-evaluation and promote positive body image.
D) Focus on educating Ms. Thomas about the long-term effects of malnutrition on her health.
A) Encourage Ms. Thomas to eat small, frequent meals to gradually increase her caloric intake.
Rationale: (A) Encouraging small, frequent meals is the best approach to gradually increase caloric intake and address malnutrition. Allowing autonomy (B) may reinforce unhealthy behaviors, and restricting mirrors (C) may not address the root cause. Education (D) is important but not the immediate priority.
The nurse is providing wound care for a patient with a chronic leg ulcer. Which intervention is most appropriate to promote healing?
A. Keeping the wound dry and covered with gauze
B. Applying an antiseptic solution directly to the wound bed
C. Maintaining a moist environment with appropriate dressing
D. Performing vigorous scrubbing to remove all debris
C. Maintaining a moist environment with appropriate dressing
Rationale: Maintaining a moist environment promotes cell growth, accelerates tissue repair, and optimizes healing.
A nurse is caring for a patient with chest pain. The patient’s troponin I level is 0.6 ng/mL. What is the appropriate nursing intervention?
A. Encourage ambulation to improve circulation
B. Continue to monitor the patient’s vital signs
C. Notify the healthcare provider immediately
D. Administer aspirin and document the findings
C. Notify the healthcare provider immediately
Rationale: A troponin I level > 0.05 ng/mL is abnormal and suggests possible myocardial injury or infarction. The nurse should immediately notify the provider.
Which of the following are risk factors for developing colorectal cancer? (Select all that apply)
A) Family history of colorectal cancer
B) Smoking
C) High-fiber diet
D) Obesity
E) Chronic inflammatory bowel disease (IBD)
A) Family history of colorectal cancer
B) Smoking
D) Obesity
E) Chronic inflammatory bowel disease (IBD)
Rationale:
Risk factors for colorectal cancer include a family history of the disease, smoking, obesity, and chronic conditions like inflammatory bowel disease (IBD). A high-fiber diet is considered protective, not a risk factor.
Ms. Emily Roberts, a 35-year-old woman, is diagnosed with generalized anxiety disorder (GAD). She reports excessive worry and difficulty relaxing, which impacts her ability to work and sleep. She has tried various coping strategies but still feels overwhelmed.
Question: Which of the following is the most appropriate initial nursing intervention for Ms. Roberts?
A) Teach Ms. Roberts how to engage in deep breathing exercises and relaxation techniques.
B) Encourage Ms. Roberts to express her anxieties openly in group therapy.
C) Recommend cognitive-behavioral therapy (CBT) as the first-line treatment for her anxiety.
D) Discuss the benefits and side effects of anti-anxiety medication.
A) Teach Ms. Roberts how to engage in deep breathing exercises and relaxation techniques.
Rationale: (A) Teaching deep breathing and relaxation techniques is an appropriate initial intervention. This provides Ms. Roberts with immediate coping strategies for anxiety. While CBT (C) and medication (D) may be effective, relaxation techniques provide more immediate relief. Group therapy (B) may be helpful but is not the priority initially.
Ms. Rachel Daniels, a 28-year-old female, has been admitted to the psychiatric unit after experiencing a manic episode. She presents with excessive energy, rapid speech, racing thoughts, and impulsive behavior (e.g., spending large sums of money). She has a history of bipolar disorder but has been non-compliant with her medication regimen for the past 6 months.
Question: Which of the following interventions should the nurse prioritize for Ms. Daniels during her acute manic episode?
A) Encourage Ms. Daniels to participate in group therapy to improve insight into her condition.
B) Provide a calm, structured environment and set limits on her behavior to prevent escalation.
C) Allow Ms. Daniels to express her thoughts freely and without interruption.
D) Encourage socialization with other patients to help her feel connected.
B) Provide a calm, structured environment and set limits on her behavior to prevent escalation.
Rationale: (B) Providing a calm, structured environment and setting limits on her behavior to prevent escalation and ensure safety. Group therapy (A) may not be effective during an acute manic episode. Allowing her to express her thoughts freely (C) may worsen her agitation, and encouraging socialization (D) may contribute to overstimulation.
A 68-year-old patient is recovering from abdominal surgery. During a routine assessment, the nurse notes the surgical wound has separated, and loops of bowel are visible. The patient reports sudden severe pain at the incision site.
What additional intervention should the nurse implement for this patient?
A. Place the patient in a high-Fowler's position
B. Administer a broad-spectrum antibiotic
C. Position the patient in a low-Fowler’s position with knees slightly bent
D. Instruct the patient to ambulate frequently to prevent pressure buildup
C. Position the patient in a low-Fowler’s position with knees slightly bent
Rationale: Keeping the patient in a low-Fowler’s position with knees bent minimizes tension on the abdominal wound and reduces the risk of further evisceration.
A patient taking warfarin has a Prothrombin Time (PT) of 25 seconds and an International Normalized Ratio (INR) of 4.2. What is the nurse’s priority action?
A. Administer vitamin K as prescribed
B. Encourage the patient to increase green leafy vegetables
C. Withhold the next dose of warfarin and notify the provider
D. Document the findings as therapeutic
C. Withhold the next dose of warfarin and notify the provider
Rationale: An INR greater than 3.0 places the patient at risk for bleeding. The nurse should withhold warfarin and notify the provider.
A patient with a history of chronic diarrhea, abdominal pain, and weight loss is diagnosed with _____, which is characterized by the inflammation of the gastrointestinal tract and includes two main types: Crohn’s disease and ulcerative colitis.
Inflammatory Bowel Disease (IBD)
Rationale:
Inflammatory Bowel Disease (IBD) encompasses conditions like Crohn’s disease and ulcerative colitis, both of which cause chronic inflammation in the GI tract and lead to symptoms such as diarrhea, abdominal pain, and weight loss. IBD is a long-term condition that can significantly affect the quality of life.
Mr. Charles Matthews, a 30-year-old male, has been admitted to the psychiatric unit after experiencing a sudden onset of symptoms including racing thoughts, irritability, and decreased need for sleep. He reports feeling "on top of the world" and is excessively talking and moving around the unit. He denies any history of mental illness but has recently gone through a stressful period of work and relationship difficulties.
Question:
Based on Mr. Matthews' symptoms and behavior, which of the following is the nurse's priority action?
A) Encourage Mr. Matthews to participate in group therapy to help him relax and gain insight into his feelings.
B) Monitor Mr. Matthews' behavior for signs of escalating mania and provide a calm and structured environment.
C) Encourage Mr. Matthews to get some rest, as sleep deprivation can often trigger mood swings.
D) Assess Mr. Matthews' understanding of his recent life stressors and encourage him to take a break from work.
B) Monitor Mr. Matthews' behavior for signs of escalating mania and provide a calm and structured environment.
Rationale: Mr. Matthews is showing signs of mania (e.g., racing thoughts, irritability, decreased need for sleep, hyperactivity). The priority is to monitor his behavior closely and ensure a calm, structured environment to prevent the escalation of symptoms.
Ms. Linda Harris, a 45-year-old female, has been admitted to the psychiatric unit after a suicide attempt by overdose. She is being treated for major depressive disorder (MDD) and has a history of previous suicide attempts. She expresses feelings of hopelessness and states, "I feel like my life isn't worth living anymore." During her assessment, she reports that she has a plan to harm herself again.
Question:
Which of the following is the nurse’s priority action in caring for Ms. Harris?
A) Encourage Ms. Harris to talk about her feelings and thoughts of hopelessness.
B) Provide Ms. Harris with information about outpatient mental health resources and therapy options.
C) Maintain a safe environment by removing any harmful objects and observing Ms. Harris closely.
D) Administer the prescribed antidepressant medication to address Ms. Harris' depressive symptoms.
C) Maintain a safe environment by removing any harmful objects and observing Ms. Harris closely.
Rationale: The priority in this situation is to ensure Ms. Harris' safety. This involves removing any harmful objects that could be used for self-harm and closely monitoring her to prevent suicide attempts.
A 68-year-old patient is recovering from abdominal surgery. During a routine assessment, the nurse notes the surgical wound has separated, and loops of bowel are visible. The patient reports sudden severe pain at the incision site.
What is the nurse’s priority action?
A. Apply dry sterile gauze over the wound
B. Administer IV pain medication as ordered
C. Cover the wound with sterile saline-soaked gauze
D. Contact the healthcare provider immediately
C. Cover the wound with sterile saline-soaked gauze
Rationale: The presence of visible bowel indicates evisceration, a medical emergency. The priority is to cover the wound with sterile saline-soaked gauze to keep the intestines moist and prevent tissue damage before contacting the provider.
Mrs. Garcia, a 68-year-old female with a history of congestive heart failure (CHF) and chronic kidney disease (CKD), presents to the emergency department with complaints of generalized weakness, abdominal cramping, and palpitations.
Assessment Findings:
Temperature: 98.2°F (36.8°C)
Pulse: 52 bpm
Respirations: 20/min
Blood Pressure: 92/60 mmHg
Laboratory Results:
Sodium: 138 mEq/L (135-145 mEq/L)
Potassium: 6.8 mEq/L (3.5-5.0 mEq/L)
Calcium: 9.0 mg/dL (9-11 mg/dL)
BUN: 45 mg/dL (10-25 mg/dL)
Creatinine: 2.8 mg/dL (0.6-1.2 mg/dL)
pH: 7.30 (7.35-7.45)
Question:
Based on Mrs. Garcia’s laboratory findings, which intervention should the nurse anticipate as the priority?
A. Administer sodium bicarbonate IV.
B. Administer calcium gluconate IV.
C. Administer regular insulin with dextrose IV.
D. Prepare the patient for emergent dialysis.
B. Administer calcium gluconate IV.
Rationale:
Mrs. Garcia’s potassium level of 6.8 mEq/L indicates severe hyperkalemia, which places her at immediate risk for life-threatening cardiac arrhythmias. The priority intervention is to administer calcium gluconate IV, which stabilizes the myocardium and helps prevent fatal dysrhythmias.
A 56-year-old patient presents to the emergency department with left lower quadrant abdominal pain, fever, nausea, and changes in bowel habits. The patient has a history of diverticulosis. The healthcare provider diagnoses acute diverticulitis. Which of the following interventions should the nurse prioritize in managing this patient?
A) Encourage the patient to consume a high-fiber diet immediately to relieve symptoms.
B) Administer intravenous fluids and antibiotics as prescribed.
C) Provide a laxative to promote bowel movements and relieve discomfort.
D) Prepare the patient for an abdominal ultrasound to confirm the diagnosis.
B) Administer intravenous fluids and antibiotics as prescribed.
Rationale:
In acute diverticulitis, the priority is to administer fluids and antibiotics to treat infection and prevent further complications. A high-fiber diet is not recommended during an acute episode, as it can exacerbate symptoms. Laxatives are contraindicated in diverticulitis because they can increase bowel motility and risk of perforation. Abdominal ultrasound may be used, but the diagnosis of diverticulitis is typically confirmed clinically.