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Assessment
Planning
Nursing Interventions
Meds
MISC
100
The nurse is admitting a severely depressed client. The nurse should expect the client to..... A) be happy the nurse is helping them B) be happy that Dr. will be ordering medications C) be withdrawn and disinterested in the admission process C) be happy that their depression will be cured.
C) be withdrawn and disinterest in the admission process. Rationale: this is part of the depression nurses should not be offended when admitting or attempting to develop a working relationship with a depressed client who responds this way.
100
A client refuses to discuss triggering events that led to the inpatient admission. Client states "I'm not going to talk about that" What is an appropriate plan? A) client will forget about why they are in psych unit. B) client will identify triggering event C) client will state why it is important to discuss triggers D) client will take medications as ordered.
B) client will identify triggering event. Rationale: Patients often do not want to discuss or deny precipitating events that brought them to the psych unit. Important for the nurse to state to them "We can discuss what some of the triggers were later" Important not to push too much.
100
An appropriate nursing intervention for caring for a client with Major Depression is: A) meet nourishment & hygiene needs B) be with the client all of the time C) have client sit and think about why they have depression. D) Tell client to "snap out of it"
A) meet nourishment & hygiene needs. RATIONALE: clients with MDD often are too depressed to meet these basic needs. The nurse should make sure and assist the client accordingly (Maslow). Additionally spending time with the client is important to establish trust. Does not need to be constantly unless a 1:1 is needed.
100
Tricyclic antidepressants have: A) peak effects in 4 days B) the most serious side effects C) high potential for overdose D) high rates of clients who inject them intravenously
C) high potential for overdose This is r/t their higher risk of cardiovascular and neurological toxicity that can result.
100
What is the most therapeutic statement: A) "You will be fine don't worry" B) "why would you feel like that?" C) "I'm sure your mother didn't mean that she loves you" D) "I'm not sure I understand can you explain that again?"
D) "I'm not sure I understand can you explain that again?" This is the most therapeutic the others are non-therapeutic "why"
200
A bipolar manic client may often exhibit behavior that is: A) passive and isolative reactions to stimuli B) exaggerated reactions to stimuli C) psychomotor retardation D) conservative and calculated
B) exaggerated reactions to stimuli Manic behaviors are often argumentative, intrusive, insultive, hyperactive, disorganized.
200
A client has a nursing diagnosis of "Powerlessness". What is an appropriate goal. A) will come to group on time B) will gain control of their life C) will identify 1 area of life client has control of. D) will sleep 9 hours each night
C) will identify 1 area of life that client has control of. This is the most appropriate goal of the choices given for the nursing diagnosis Powerlessness. Will gain control of life is too vague and not measurable.
200
Appropriate nursing interventions for a depressed patient would be: (select all that apply) A) plan activities that promote success B) provide simple schedules to follow C) brief frequent interactions with the client D) promise client that you will keep their secret E) place client in seclusion
A, B,C You would never promise to keep a secret with a client and seclusion will add to depression.
200
Clients on MAO inhibitors should avoid what foods to prevent hypertensive crisis. A) chicken breast & salad B) Steak & asparagus C) Bologna & cheese D) Oatmeal & milk
C) Bologna & cheese People on MAO inhibitors should avoid foods high in Tyramine: aged cheese and wine, beer, chocolate, cola, tea, coffee, smoked and processed meats, overripe or fermented foods (yogurt, yeast products soy sauce)
200
The nurse is explaining ECT to a patient. What is a potential side effect/complication of ECT? A) tachycardia B) hemorrhage C) memory disturbance D) burns from the temporal probes.
C) memory disturbances Patients who have ECT will present "post ictal" and may have some memory problems from the procedure.
300
A client states to the nurse "doesn't matter I'm not going to be around here long anyways". The nurse should..... A) obtain order for 1:1 supervision B) focus on positive aspects of clients life C) engage client in multiple group activities D) allow client to take a nap since they have had poor sleep.
A) obtain order for 1:1 supervision Statements such as these should be taken seriously. If client cannot commit to being safe or nurse is worried about suicide. The client should be on 1:1 supervision for safety.
300
An appropriate short term goal for a manic client would be: A) engage in a competitive activity B) Will sit quietly and write in journal C) will interact with other clients on the unit D) will share feelings in group
B) will sit quietly and write in a journal. This is the best because manic behaviors are often hyper and inappropriate and lack focus. If you can get them to sit and focus on an activity or game (journaling, solitaire, coloring) that shows an increased ability to focus which is positive.
300
The nurse suspects a client is suicidal. What is the best way to determine this? A) observe client for sign of suicide B) Discuss the clients feelings about life C) Ask the client if they are suicidal D) Ask the family if the client has past suicide attempts
C) Ask the client if they are suicidal. This is the best response to ask the client directly if they have thoughts of hurting themselves. Certainly asking the family, if available and client consents, is helpful for history but direct questions to the client are the best.
300
Teaching for patients on antidepressants would include: (select all that apply) A) dry mouth is common B) nausea may occur C) may stop if feeling better D) do not stop abruptly E) sedation may occur
A) dry mouth B) nausea may occur D) do not stop abruptly E) sedation may occur.
300
Normal grief response........ A) is severe and provokes suicidal thought in survivor B) severely impairs persons ability to function C) is progressive course that changes over time D) lasts a short period of time
C) is progressive that changes over time. Grief is a process that is ever changing. Has stages of denial, anger, bargaining, depression, acceptance. Life events such as anniversary of death, birthdays, holidays can provoke feelings of grief.
400
A client with depression presents with c/o HA and abdominal pain. The nurse recognizes this as a _____ complaint. A) delusional B) Somatic C) exacerbated D) Behavioral
B) Somatic Patients with depression will often have somatic complaints (HA, pain etc). It is important for the nurse to help the patient recognize that physical symptoms are often exacerbated by specific stressors.
400
A priority goal for a client in an acute manic state would be: A) client will not harm self B) client will sit and write in journal C) client will sleep 6 hours D) client will eat 3 meals a day
A) client will not harm self. Safety is priority. All others are good goals but not priority. Think Maslow.
400
Which would be the most appropriate intervention for a client experiencing mania. A) Provide frequent interactions with other clients B) provide high calorie finger foods to client C) Provide seclusion for all intrusive behavior D) provide many choices and activities for client to do.
B) provide high calorie finger foods to the client. Manic patients burn a lot of calories from the hyperactive behavior and often cannot sit to focus on eating. High calorie finger foods provide adequate nutrition and calories that the patient can eat when moving around.
400
Treatment for MAO Hypertensive Crisis includes: A) stop med, give long acting b/p med B) stop med, give short acting b/p med C) continue med, give long acting b/p med D) continue med, give short acting b/p med
B) stop the med give short acting b/p med HTN crisis s/s include: HA, high b/p, n/v, palpitations, nucal rigidity, fever chest pain. coma.
400
A client has been working on a letter to his wife for one week. The letter is poorly written and has several spelling errors. The nurses best response is: A) "You did an excellent job on this letter be proud" B) "You have worked very hard on this letter" C) "You did a great job but you need to correct spelling" D) "You should add more to this letter"
B) "You have worked very hard on this letter" This is the best response because it identifies the work the client has put forth without giving false information on how great the letter is when it really is poorly done (spelling errors illogical sentences etc...).
500
A bipolar patient is taking lithium. The nurse assesses that the client has diarrhea, n/v, tinnitus, tremors, and increased confusion. The nurse suspects..... A) this is a normal side effect of lithium B) patient is experiencing lithium toxicity C) patient has not yet reached therapeutic lithium levels
B) patient is experiencing lithium toxicity. Therapeutic range is 0.6-1.2 Levels >1.5 indicate toxicity. The above s/s suggest lithium toxicity in a patient who is on lithium as a antimanic medication.
500
While preparing a patient for ECT treatment the nurse should plan to: A) administer muscle relaxant after b/p cuff is placed B) administer muscle relaxant before b/p cuff is placed C) place b/p cuff on both legs first then give muscle relaxer C) do not place b/p cuff on patient at all
A) administer muscle relaxant after b/p cuff is placed Rationale: placing b/p cuff on lower leg first and then giving muscle relaxant prevents the muscle relaxer from getting down to that leg. This ensures that seizure activity can be observed in one limb that is unaffected by the muscle relaxant.
500
A priority intervention for a client with suicidal ideations is: A) regular rounds to ensure safety B) Irregular unobtrusive rounds to ensure safety C) allow client to spend time in room all day D) lock client out of room all day for safety
B) Irregular unobtrusive rounds to ensure safety. Rounding on the floor to observe the patient is important for safety. You do not want the patient to develop a pattern of when to expect the nurse to be checking on them for safety.
500
A client is taking 2 different SSRI's. The nurse should be alert for what syndrome? A) serotonin syndrome B) Neuroleptic malignant syndrome C) EPS syndrome D) Parkinsons syndrome
A) serotonin syndrome Serotonin syndrome is a rapid onset that presents as: change in mental status, restlessness, hyper-reflexia, shivering/ tremors, hyperthermia, labile b/p, tachycardia. Patients at high risk for this are those who take 2 or more meds that increase serotonin levels.
500
What is the most therapeutic to say to a client? A) Why are you tapping your foot? B) Do you realize you are tapping your foot? C) You seem anxious tell me how you are feeling. D) You shouldn't tap your foot it is distracting to other clients.
C) You seem anxious tell me how you are feeling. This is sharing observations and provides open ended question to the client to expand more on how they are feeling.