Anxiety
A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?
A. Tachycardia, diaphoresis, and a sense of impending doom
B. Confusion, difficulty concentrating, and a feeling of dread. C. Vague feelings of discomfort, restlessness, racing thoughts
D. Hallucinations, delusions, and disorganized thinking
C. Vague feelings of discomfort, restlessness, racing thoughts
Rationale: Mild- Part of everyday living, Prepared for action, ID cause of anxiety, vague feelings of discomfort
A nurse in the ICU is caring for a client who developed serotonin syndrome after taking fluoxetine with tramadol. Which assessment finding requires immediate intervention?
A. Hyperreflexia and clonus in the lower extremities
B. Temperature of 103.5°F (39.7°C) and muscle rigidity
C. Agitation and dilated pupils
D. Tachycardia and diaphoresis
B. Temperature of 103.5°F (39.7°C) and muscle rigidity
A nurse is caring for a client with bipolar disorder, manic episode. Which of the following is the most common characteristic of mania?
A) Low energy and feelings of worthlessness
B) Increased talkativeness and excessive energy
C) Slow speech and poor concentration
D) Social withdrawal and lack of interest in activities
B) Increased talkativeness and excessive energy
A nurse is assessing a client with anorexia nervosa. Which of the following findings is most characteristic of this disorder?
A) Recurrent episodes of binge eating followed by purging
B) Fear of gaining weight despite being underweight
C) Consumption of large amounts of food in a short period
D) Use of excessive insulin to induce weight loss
B) Fear of gaining weight despite being underweight
What are the levels for therapeutic lithium in the blood
0.8-1.4 meq/L
A nurse in the emergency department is caring for a client experiencing a panic attack. Which of the following actions should the nurse take first?
A. Stay with the client and speak in a calm, reassuring manner.
B. Teach the client deep breathing exercises.
C. Encourage the client to discuss what triggered the attack.
D. Administer prescribed benzodiazepine medication immediately.
A. Stay with the client and speak in a calm, reassuring manner.
Rationale: Panic- Assure patient safety, STAY WITH PATIENT, use LRC, patient often get restraints and given ETO
A nurse is caring for a client diagnosed with major depressive disorder (MDD). Which of the following statements by the client indicates the highest risk for suicide and requires immediate intervention?
A. "I feel so hopeless. I don't think things will ever get better."
B. "Its been a couple days, I don't think the fluoxetine is working"
C. "Sometimes I wish I could just go to sleep and never wake up."
D. "I don’t want to be a burden to my family anymore."
D. "I don’t want to be a burden to my family anymore."
A nurse is caring for a client experiencing a manic episode due to bipolar I disorder. The client is pacing the room, talking loudly, and interrupting others. The client suddenly points at the nurse and says, "You! You need to help me start my new business right now! I have the best idea, and we have to act fast!"
A) "Tell me more about your business idea. It sounds interesting."
B) "You're too agitated right now. Let’s sit down and take some deep breaths."
C) "I can see you're excited. Let’s take a break and have a snack."
D) "You need to calm down. Your idea isn’t realistic right now."
C) "I can see you're excited. Let’s take a break and have a snack."
A nurse is assessing a client with bulimia nervosa. Which of the following findings should the nurse expect?
A) Erosion of tooth enamel
B) Lanugo (fine body hair) on the arms and back
C) Calluses on the knuckles
D) Impaired fluid and electrolyte balance
E) Normal or slightly overweight body weight
A,C,D,E
Medication provided for sexual dysfunction
Bupropion
A nurse is providing education to a client who has been prescribed buspirone for generalized anxiety disorder. Which of the following statements by the client indicates a need for further teaching?
A. "I should take this medication every day to see its full effects."
B. "Unlike benzodiazepines, this medication is less likely to cause dependence."
C. "It may take a few weeks before I notice an improvement in my anxiety."
D. "I can take this medication as needed when I start feeling anxious."
D. "I can take this medication as needed when I start feeling anxious."
What does the E in "For Extra Sleepy Clients Please" stand for
Escitalopram
A nurse is planning dietary recommendations for a client experiencing a manic episode due to bipolar I disorder. Which of the following food options are most appropriate for this client? (Select all that apply.)
A) Peanut butter and jelly sandwich
B) Grilled chicken with steamed vegetables
C) Cheese and crackers
D) Spaghetti with meatballs
E) Apple slices with almond butter
A nurse is caring for a client with anorexia nervosa who was admitted for severe malnutrition. The client has a BMI of 14, reports feeling fine and not needing food, and has a potassium level of 2.9 mEq/L. Which of the following interventions is the priority?
A) Encourage the client to join a group therapy session on body image.
B) Begin nutritional rehabilitation with a high-calorie diet.
C) Initiate continuous cardiac monitoring.
D) Discuss the client’s distorted body image and reinforce healthy eating habits.
C) Initiate continuous cardiac monitoring.
Type of therapy used for PTSD in children
Art and play therapy
A nurse is developing a care plan for a client recently diagnosed with obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include? (Select all that apply.)
A. Set strict time limits for compulsive behaviors and enforce immediate redirection.
B. Encourage the client to verbalize feelings of anxiety rather than performing compulsions.
C. Allow the client to perform compulsions initially, then gradually introduce response prevention techniques.
D. Teach the client to use cognitive reframing to challenge obsessive thoughts.
E. Encourage avoidance of situations that trigger obsessive thoughts to reduce anxiety.
F. Assist the client in identifying alternative coping mechanisms for anxiety management.
B,C,D,F
The nurse is providing discharge teaching to a client who has been prescribed phenelzine for major depressive disorder. Which statement by the client indicates a need for further teaching?
A. "I will avoid foods like aged cheese and smoked meats while taking this medication."
B. "I need to stop taking my over-the-counter cold medicine while on this drug."
C. "If I experience a severe headache and a rapid heartbeat, I should lie down and rest."
D. "It may take a few weeks before I start to feel the full effects of this medication."
C. "If I experience a severe headache and a rapid heartbeat, I should lie down and rest."
A nurse is caring for a client experiencing a manic episode due to bipolar I disorder. The client is pacing rapidly, clenching their fists, and shouting at staff and other clients, saying, "None of you understand! Get out of my way before I make you!"
A) "You need to stop yelling. This behavior is not acceptable."
B) "I can see you're upset. Let’s go to a quieter area to talk."
C) "Place the client in restraints, then notify the provider to increase dose of antipsychotic."
D) "Take some deep breaths and think about what you're saying."
B) "I can see you're upset. Let’s go to a quieter area to talk."
A nurse is assessing a client with bulimia nervosa who has a history of self-induced vomiting. The client reports feeling weak and dizzy. Which of the following findings requires the nurse’s immediate intervention?
A) Irregular heart rate of 48 beats per minute
B) Bilateral parotid gland swelling
C) Erosion and sanguineous drainage of tooth enamel
D) Calluses on the knuckles (Russell’s sign)
A) Irregular heart rate of 48 beats per minute
Three meds that treat hyperarousal in PTSD
Clonidine, Prazosin, Propanolol
A nurse is caring for a client who frequently reports multiple physical symptoms, including chronic pain and fatigue, despite negative diagnostic tests. Which of the following nursing interventions are appropriate for this client? (Select all that apply.)
A. Perform a comprehensive physical assessment to rule out underlying medical conditions.
B. Reinforce that the client’s symptoms are “not real” and focus on psychological factors.
C. Encourage the client to focus on daily activities and coping strategies rather than physical symptoms.
D. Schedule regular, brief appointments to discuss symptoms rather than responding to every complaint immediately.
E. Provide consistent, matter-of-fact care while minimizing reinforcement of the sick role.
A, C, D, E
A 25-year-old client with major depressive disorder has been prescribed phenelzine. During a follow-up visit, the client reports feeling dizzy and having a severe headache after attending a wine and cheese event. The nurse's priority action is to
A) Administer acetaminophen for headache relief.
B) Monitor the client’s blood pressure closely.
C) Instruct the client to increase fluid intake to prevent dehydration.
D) Encourage the client to rest in a quiet, dark room.
B) Monitor the client’s blood pressure closely.
Phenelzine is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client consumes tyramine-rich foods (e.g., aged cheeses, wine, cured meats). A severe headache and dizziness are early signs of a hypertensive crisis, which can lead to stroke if untreated.
A 30-year-old client with bipolar I disorder, manic episode, is admitted to the psychiatric unit. The client is pacing the hallways, loudly proclaiming they have discovered the cure for cancer. The client refuses medications, stating, "I don’t need them! I’m smarter than the doctors!" The nurse notes the client has not slept for two nights and is rapidly shifting between topics during conversation.
A) Assess vital signs and administer haloperidol immediately
B) Offer a quiet, low-stimulation environment to help the client rest.
C) Set firm limits on disruptive behavior and provide structured activities.
D) Implement 1:1 supervision and assess for exhaustion and dehydration.
D) Implement 1:1 supervision and assess for exhaustion and dehydration.
A nurse is caring for a client with severe anorexia nervosa who has just started nutritional rehabilitation. After two days of refeeding, the client develops muscle weakness, confusion, and irregular heartbeats. Which of the following laboratory findings should the nurse expect?
A) Elevated sodium and hyperglycemia
B) Hypokalemia, hypophosphatemia, and hypomagnesemia
C) Metabolic acidosis with low bicarbonate levels
D) Increased calcium and metabolic alkalosis
B) Hypokalemia, hypophosphatemia, and hypomagnesemia
Illness characterized by imposing factitious symptoms on someone else.
Munchausens by proxy