Assessment
A nurse is conducting an initial assessment for a client suspected of having Major Depressive Disorder. Which assessment finding would be most indicative of MDD?
a) Increased energy levels and rapid speech
b) Consistent feelings of sadness, hopelessness, and worthlessness
c) Occasional feelings of irritability and frustration
d) Periodic episodes of euphoria and grandiosity
b) Consistent feelings of sadness, hopelessness, and worthlessness
A nurse is educating a client diagnosed with Major Depressive Disorder about the prescribed treatment plan. Which statement by the client indicates a good understanding of the recommended treatment?
a) "I'll stop taking the medication once I start feeling better."
b) "I'll rely solely on herbal remedies and avoid prescription medications."
c) "I'll only take the medication when I experience severe depressive episodes."
d)"I'll attend therapy sessions regularly and engage in talk therapy."
d) "I'll attend therapy sessions regularly and engage in talk therapy."
A nurse is providing safety education to a client prescribed fluoxetine. Which statement by the client demonstrates a clear understanding of safety measures and nurse education specific to fluoxetine treatment?
a) "I can have a glass of wine occasionally."
b) "It's okay to skip my dose if I don't feel like taking the medication on certain days."
c) "If I experience any side effects, I'll immediately discontinue fluoxetine to alleviate them."
d) "I'll monitor for potential serotonin syndrome symptoms, such as confusion or muscle twitching, and report them promptly to my healthcare provider."
d) "I'll monitor for potential serotonin syndrome symptoms, such as confusion or muscle twitching, and report them promptly to my healthcare provider."
A nurse is caring for a patient diagnosed with depression. Which defense mechanism is the patient most likely to use as a way of coping with overwhelming emotions?
a) Regression
b) Displacement
c) Rationalization
d) Sublimation
a) Regression
A nurse is caring for a patient who has recently been prescribed sertraline. Which statement by the patient indicates a need for further education on medication management?
a) "I'll continue taking the medication even if I start feeling better to prevent a relapse."
b) "If I experience bothersome side effects, I'll stop the medication and inform my healthcare provider."
c) "It may take a few weeks before I notice the full therapeutic effects of the antidepressant."
d) "I'll avoid consuming alcohol while taking this medication to prevent interactions."
b) "If I experience bothersome side effects, I'll stop the medication and inform my healthcare provider."
Question: A nurse is assessing a client for possible bipolar disorder. Which assessment finding is characteristic of the manic phase of bipolar disorder?
a) Persistent low energy and feelings of worthlessness
b) Periods of intense euphoria, increased energy, and decreased need for sleep
c) Recurrent episodes of overwhelming sadness and loss of interest in activities
d) Excessive worry and anxious thoughts about various life events
b) Periods of intense euphoria, increased energy, and decreased need for sleep
A nurse is providing education to a client diagnosed with bipolar disorder experiencing a manic episode. Which intervention is essential for the nurse to include in the teaching plan for the management of bipolar mania?
a) Promoting consistent and adequate sleep patterns.
b) Encouraging the client to engage in strenuous physical exercise.
c) Allowing the client to make impulsive decisions independently.
d) Suggesting the regular consumption of caffeinated beverages.
a) Promoting consistent and adequate sleep
A nurse is providing education to a client diagnosed with bipolar disorder prescribed with lithium as a mood stabilizer. Which statement by the client indicates a clear understanding of safety measures and nurse education regarding lithium treatment?
a) "I can adjust the lithium dosage based on my mood to enhance its effectiveness."
b) "If I experience any side effects, I'll discontinue lithium immediately to avoid complications."
c) "I'll maintain consistent sodium intake in my diet to prevent lithium toxicity."
d) "Skipping lithium doses occasionally won't impact its therapeutic benefits."
c) "I'll maintain consistent sodium intake in my diet to prevent lithium toxicity."
A nurse is providing care to a client diagnosed with depression. What is the most appropriate nursing intervention to allow time for effective communication with the depressed client?
a) Schedule frequent and lengthy counseling sessions to explore underlying issues.
b) Limit interactions to short, focused periods to prevent overwhelming the client.
c) Encourage the client to engage in distracting activities during communication.
d) Insist on immediate responses to ensure active participation in conversations.
b) Limit interactions to short, focused periods to prevent overwhelming the client.
A nurse is developing a care plan for a patient diagnosed with Major Depressive Disorder. What should be the nurse's priority interventions and education to address both acute and chronic psychosocial health issues associated with depression?
a) Focus on immediate symptom relief through medication management and crisis intervention.
b) Encourage the patient to explore the root causes of depression during counseling sessions.
c) Collaborate with the patient to establish short-term and long-term goals for mental health.
d) Provide information on community resources and support groups for ongoing mental health maintenance.
c) Collaborate with the patient to establish short-term and long-term goals for mental health.
A nurse is assessing a client for possible somatic symptom disorder. Which characteristic is often observed in individuals with somatic symptom disorder?
a) Openly discussing emotional distress and seeking psychological support
b) Experiencing physical symptoms without a clear medical cause
c) Regular engagement in social activities to distract from physical discomfort d
) Easily accepting reassurance from healthcare providers about their health
b) Experiencing physical symptoms without a clear medical cause
A nurse is caring for a client diagnosed with Somatic Symptom Disorder (SSD). Which therapeutic intervention is a priority in the client's care plan?
a) Ordering extensive diagnostic tests to rule out any potential medical conditions.
b) Administering pain medication to alleviate the reported somatic discomfort.
c) Encouraging the client to express emotions related to their physical symptoms.
d) Allowing the client to dictate the frequency and intensity of medical appointments.
c) Encouraging the client to express emotions related to their physical symptoms.
A nurse is educating a client prescribed venlafaxine for the treatment of depression and anxiety. The client asks about potential drug interactions. Which response by the nurse reflects a comprehensive understanding of venlafaxine's pharmacology?
a) "There are no significant drug interactions with venlafaxine, so you can take any over-the-counter medication without concern."
b) "It's crucial to inform your healthcare provider about all prescribed and over-the-counter medications, as some may interact with venlafaxine. "
c) "Avoiding foods high in tyramine, like aged cheese and cured meats, is essential to prevent interactions with venlafaxine."
d) "You can safely take herbal supplements like St. John's Wort concurrently with venlafaxine to enhance its therapeutic effects."
b) "It's crucial to inform your healthcare provider about all prescribed and over-the-counter medications, as some may interact with venlafaxine."
A nurse is engaging in therapeutic communication with a client diagnosed with Bipolar Disorder during a manic episode. Which communication technique is most appropriate for managing the client's heightened energy and impulsivity?
a) Encouraging the client to explore the consequences of impulsive actions.
b) Providing detailed explanations of the potential risks associated with manic behavior.
c) Setting firm limits on behavior while maintaining a calm and non-confrontational demeanor.
d) Using humor and redirection to confirm the client from impulsive thoughts.
c) Setting firm limits on behavior while maintaining a calm and non-confrontational demeanor.
A nurse is assessing clients on a psychiatric unit. Which client is likely experiencing mania?
a) The client who has maintained a consistent and stable mood for several weeks.
b) The client with a history of depressive episodes but currently reports feeling calm and content.
c) The client exhibits impulsivity, pressured speech, flight of ideas, and sleeps one hour each night.
d) The client practicing coping strategies and actively engaging in therapeutic activities.
c) The client exhibits impulsivity, pressured speech, flight of ideas, and sleeps one hour each night.
A nurse is assessing a client with generalized anxiety disorder. Which behavioral manifestation is commonly observed in individuals with GAD?
a) Hyperactivity and restlessness
b) Avoidance of social situations
c) Periods of deep sadness and tearfulness
d) Slurred speech and difficulty concentrating
b) Avoidance of social situations
A nurse is caring for a client diagnosed with Generalized Anxiety Disorder. Which intervention is a priority in the client's care plan?
a) Administering a benzodiazepine as a long-term maintenance medication.
b) Encouraging the client to avoid any situations that trigger anxiety.
c) Incorporating cognitive-behavioral therapy (CBT) into the treatment plan.
d) Allowing the client to manage the dosage of prescribed medications independently.
c) Incorporating cognitive-behavioral therapy (CBT) into the treatment plan.
A nurse is discussing the potential side effects of lithium treatment with a client diagnosed with bipolar disorder. Which statement by the client suggests an accurate understanding of the association between lithium and weight gain?
a) "I'll follow a low-sodium diet to minimize the risk of weight gain while on lithium."
b) "Regular exercise is crucial to counteract the weight gain associated with lithium."
c) "I can increase my calorie intake since lithium tends to suppress appetite."
d) "I should monitor my weight regularly as lithium can lead to weight gain in some individuals."
d) "I should monitor my weight regularly as lithium can lead to weight gain in some individuals."
A mental health nurse is engaging with a client experiencing heightened anxiety. Which communication technique is most appropriate for providing support and helping the client manage their anxiety?
a) Encouraging the client to explore and express their deepest fears.
b) Offering immediate solutions and advice to address the source of anxiety.
c) Providing detailed explanations about the potential positive outcomes of anxiety-provoking situations.
d) Using active listening and reflecting the client's feelings to validate their emotional experience.
d) Using active listening and reflecting on the client's feelings to validate their emotional experience.
A nurse is assessing clients on a psychiatric unit. Which client is likely experiencing a depressive episode?
a) The client who has been consistently attending therapy sessions and participating in group activities.
b) The client practicing mindfulness techniques and actively engaging in self-care activities.
c) The client who reports occasional fluctuations in mood but generally expresses feelings of hope and contentment.
d) The client exhibiting symptoms of severe apathy, withdrawal, and a momentous decline in functioning.
d) The client exhibiting symptoms of severe apathy, withdrawal, constipation, and a momentous decline in functioning.
A nurse is assessing a client for possible post-traumatic stress disorder (PTSD). Which symptom is often indicative of PTSD?
a) Periodic episodes of intense happiness and elation
b) Intrusive and distressing memories of a traumatic event
c) Persistent feelings of worthlessness and hopelessness
d) Excessive worry about various aspects of life
b) Intrusive and distressing memories of a traumatic event
A nurse is developing a care plan for a client diagnosed with a specific phobia. Which intervention is a priority in the client's treatment?
a) Gradual exposure therapy to the feared object or situation.
b) Random confrontations with the feared object to desensitize the client.
c) Administering anxiolytic medications for long-term symptom relief.
d) Advising the client to avoid the feared object to prevent distress.
a) Gradual exposure therapy to the feared object or situation.
A nurse is caring for an inpatient diagnosed with depression who has recently started treatment with a citalopram. What is the nurse's priority action concerning safety during the inpatient stay?
a) Administering citalopram at the same time each day to maintain consistency.
b) Allowing the client unrestricted access to personal belongings for comfort.
c) Conducting regular assessments for signs of increased suicidal ideation or agitation.
d) Encouraging group therapy sessions for distraction and peer support.
c) Conducting regular assessments for signs of increased suicidal ideation or agitation.
A nurse interacts with a client diagnosed with Somatic Symptom Disorder. Which communication technique is most appropriate for addressing the client's physical symptoms while acknowledging their distress?
a) Asking why the client insists on discussing physical discomfort.
b) Offering immediate solutions and advice to address the perceived physical issues.
c) Validating the client's concerns and expressing empathy without reinforcing the symptoms.
d) Suggesting the client engage in activities to distract from somatic complaints.
c) Validating the client's concerns and expressing empathy without reinforcing the symptoms.
A mental health nurse is engaging with a client currently experiencing heightened energy, impulsivity, and rapid speech. Which comprehensive communication techniques should the nurse prioritize for effectively managing the client's symptoms? Select all that apply.
a) Providing structure opportunities for client to interact with peers and staff.
b) Setting clear and consistent boundaries while maintaining a non-confrontational approach.
c) Actively listen to the client's thoughts and give advice on each thought.
d) Identifying and avoiding potential triggers for impulsive behaviors.
e) Using redirection to gently guide the client to a calmer and less stimulating environment.
a) Providing structure opportunities for client to interact with peers and staff.
b) Setting clear and consistent boundaries while maintaining a non-confrontational approach.
e) Using redirection to gently guide the client to a calmer and less stimulating environment.