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50 Cards in this Set
- Front
- Back
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The nurse in the mental health unit of the hospital is doing an assessment on a patient. Which of the following would determine that the patient is most likely suffering from Dysthymia?
a. Patient regularly experiencing depressive symptoms almost every day over a 2-week period b. Depressive symptoms that occur over a 2 year period c. Symptoms that may include psychotic, catatonic, and melancholic features d. History of one or more major depressive episodes and no history of manic or hypomaniac episodes |
B. dysthymia is characterized by a chronic depressive syndrome that is usually present for at least 2 years.
major depressive disorder is characterized by depressive symptoms experienced almost every day over a 2-week period that may include psychotic, catatonic, and melancholic features. History of one or more major depressive episodes without history of manic or hypomaniac episodes is also presented. |
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a person who experiences anhedonia:
a. Lacks the ability to experience joy or pleasure in living b. Lacks energy or passivity c. Experiences excessive amount of sleepiness d. Experiences delusions or hallucinations |
A. anhedonia describes a person’s lack of ability to experience joy or pleasure in living and is a hallmark of depression.
anergia is the lack of energy or passivity. hypersomnia describes an excessive amount of sleepiness. delusional or psychotic major depression is a severe form of mood disorder and characterized by delusions or hallucinations. |
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a patient in a mental health facility was diagnosed with depression was started on a low dose antidepressant. 3 days later, the patient reported having a lot of energy to do things and always having a “good mood”. The nurse taking care of the patient would take note that the patient’s sudden change in behavior indicates:
a. That the antidepressant drug has reached therapeutic effect b. The patient can be sent home due to the improved behavior c. An increased suicide potential due to sudden elevated mood d. The patient is experiencing another mental disorder and must be reassessed immediately |
C. patients diagnosed with depression that show a sudden elevated mood, or energy are at a high risk for suicidal attempts. – a depressed suicidal person may suddenly appear better after making a decision to end their life.
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The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client with severe depression. The most reliable evaluation of outcomes will be based on:
a. Client statement of appetite b. Observed eating patterns c. Weekly weights d. Energy level |
C. Client body weight is the most reliable and objective evaluation of success in treating this nursing diagnosis.
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Which patient statement indicates learned helplessness?
a. “I hate myself” b. “It's all my fault that my husband left me for another woman” c. “Everyone in the world is just out to get me.” d. “I am a horrible person.” |
B. Learned helplessness often occurs during depression if the person feels no control over the outcome of a situation. By blaming herself, the patient has taken accountability for her husband’s actions and assigned blame to herself.
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The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be the priority on the nurse's discharge plan of care?
a. Awareness of symptoms increasing depression b. The need for interpersonal contact c. Pharmacological teaching d. Safety risk |
D. Safety is always the highest priority in planning care. Even if the patient has not exhibited a risk for self-harm, the potential for this must be addressed with patients who have depression
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A patient with depression who usually takes an SSRI type of antidepressant is now going to switch to an MAOI antidepressant. One important information the nurse should tell the patient about the drugs is:
a. The patient should take one of each type of medication everyday b. The patient may combine both medications if the patient wishes to do so c. The patient should discontinue all SSRIs for 2 – 5 weeks before starting the MAOI d. Patient should take both SSRIs and MAOIs for 2-5 weeks to receive full therapeutic effect of the drugs |
C. patient must discontinue the SSRIs for 2-5 weeks before switching to the MAOI to prevent central serotonin syndrome
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A nurse in a mental health facility is doing a patient teaching to a client with depression about MAOI medications. Which of the following foods should the nurse tell the patient to avoid while on the medication? [select all that apply]
a. Avocados b. Bananas c. Cheese d. Soy products |
All of the above. Foods high in tyramine (e.g., avocados, bananas, cheese, soy) can cause high blood pressure, hypertension, and can eventually lead to a CVA
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A nurse is taking care of a patient who was recently diagnosed with bipolar disorder, which of the following characteristics or symptoms of the patient that would support the diagnosis? [select all that apply]
a. Highly distractible b. Inflated self esteem or grandiosity c. Patient is withdrawn, not talking too much d. Patient has poor judgment – impulsivity, lack of control |
A,B, D. someone who has bipolar disorder is highly distractible, has an inflated self esteem or grandiosity, more talkative than usual, and has poor judgment
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What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?
a. bradycardia and increased thirst b. Muscle stiffness and shuffling gait c. Headache and palpitations d. Confusion and sore throat |
C. headache, palpitations, and sudden elevation of blood pressure are some of the symptoms of a hypertensive crisis related to tyramine consumption.
Muscle stiffness and shuffling gait are related to extrapyramidal side effects of antipsychotics |
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A mental health nurse is doing her rounds on the unit. She passed by a patient with bipolar disorder talking to another patient. Which statement of the patient with bipolar disorder should the nurse acknowledge and give more attention to?
a. “I saw a squirrel earlier and saw it eating a piece of bread. I know it’s a piece of bread because it was mine. I gave the squirrel a piece of bread.” b. “I’m going to draw pictures and art. I love doing art. Art is my favorite thing to do. I just love colors and art.” c. “I’m going to sell my art and make a million, no, a bazillion dollars because my art is so good, I’m the best art person in the whole world and everyone will buy my art because I’m the best.” d. “I saw an art show on TV and I just love all the art and I’m going to buy all of it later when I get back to my room and get my credit card. I’ll buy all the art on TV and every art that I can see.” |
D. a person with bipolar disorder may have poor judgment (lack of self control) and impulsivity. The nurse may have to provide appropriate interventions when the patient expressed unrestrained or impulsive buying.
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A nurse is tasked to do an assessment on a patient who has bipolar disorder. Which question should the nurse ask the patient in order to get a good patient assessment?
a. “what have you been working on since this morning?” b. “when is the last time you ate or slept?” c. “what do you want to do today?” d. “when is the last time you talked with your primary physician?” |
B. One of the most important assessments for someone who has bipolar disorder is to ask when the patient last ate or slept.
Patients with bipolar disorder may become hyperactive and non-stop physical activity and lack of sleep and food can lead to physical exhaustion and even death if not treated |
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A nurse in the mental health facility is planning to care for a client who is experiencing the acute phase of bipolar disorder. Which of the following interventions is/are appropriate for the nursing care plan for the client? [select all that apply]
a. Maintaining medication compliance b. Psychoeducational teaching for the client and the family c. Medication stabilization and safety d. Prevent relapse |
C. during the acute phase, planning focuses on medically stabilizing the patient while maintaining safety.
Planning for the continuation phase focuses on maintaining medication compliance and psychoeducational teaching for the client and the family. During the maintenance phase, planning focuses on preventing relapse and limiting the severity and duration of future episodes. |
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Patients with bipolar disorder who take lithium are also taking what type of medication as initial treatment of acute mania until the lithium takes effect?
a. Antipsychotics b. Antiarrythmias c. Antidepression d. Anticoagulant |
A. lithium usually takes 7 – 14 days to reach therapeutic levels. An antipsychotic / benzodiazepine can be used to prevent exhaustion, coronary collapse, and death until lithium reaches therapeutic levels
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A 35 year old male client who’s taking lithium for bipolar disorder calls his healthcare provider and complains of nausea and vomiting, polyuria, and muscle weakness. The most appropriate response that the healthcare provider tells the client is:
a. “It’s just a mild side effect of the drug. It will subside in a couple of days.” b. “You should limit your food and fluid intake so you won’t experience those side effects.” c. “You should stop taking the medication and go to the hospital as soon as possible” d. “That means the medication isn’t working appropriately so we should increase the dosage of your medication” |
C. the patient should withhold the medication and go to the healthcare facility because the patient is experiencing early signs of lithium toxicity
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A nurse is doing a patient teaching session with a client who is recently diagnosed with bipolar disorder and prescribed to take lithium. The patient mentioned “I’m also taking Lasix, can I take it with lithium?” the nurse’s response should be:
a. “take your diuretics in the morning and your lithium at night.” b. “you can’t take diuretics while you’re taking lithium” c. “you can alternately take both medications. Like if you take your Lasix today, you should take your lithium tomorrow” d. “you can take both medications at the same time” |
B. Loop diuretics may increase serum lithium levels and potentiate the risk of lithium toxicity.
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The nurse is planning care for a patient experiencing the acute phase of mania. Which is the priority intervention?
a. Prevent injury b. Get the patient to demonstrate thought self-control c. Maintain stable cardiac status d. Ensure that the patient gets sufficient sleep and rest |
A. Safety is always the highest priority in planning care. All other interventions may be included in the plan of care, but the priority is to keep the patient safe.
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When a client experiences 4 or more mood episodes in a 12 month period, the client is said to be:
a. Cyclothymic b. Rapid-cycling c. Dysynchronous d. Incongruent |
B. Rapid cycling infers 4 or more mood episodes in a 12 month period as well as more severe symptoms
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To plan care for a manic client the nurse must consider that lithium cannot be started until:
a. seclusion has proven ineffective as a means of controlling assaultive behavior b. the initial doses of antipsychotic medication have brought behavior under control c. electroconvulsive therapy can be scheduled to coincide with lithium administration d. the physical examination and laboratory tests are analyzed |
D. Lithium should not be given to clients with impaired renal or thyroid function. A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally.
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Assessment of thought processes of a client with depression is most likely to reveal:
a. good memory and concentration b. self-deprecatory ideation c. delusions of persecution d. sexual preoccupation |
B. Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world.
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Which side effects commonly occur in clients who are taking SSRI antidepressants?
a. Extrapyramidal side effects b. Anticholinergic effects c. Neuroleptic malignant effects d. Gastrointestinal disturbances |
D. GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual dysfunction, are common with SSRIs.
Anticholinergic effects are more common with tricyclic antidepressants than with SSRI antidepressants. Extapyramidal side effects are common with the traditional antipsychotic medications. Neuroleptic malignant syndrome can be fatal. It is a serious side effect of antipsychotic medications. |
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A client with depression was put on constant observation after the client attempted to commit suicide. The nurse is tasked to reassess the need to maintain safety precautions on the patient. What will ensure that the client will be safe?
a. There are no items in the client's room to cause self-harm b. Client reports feeling less depressed and sleeping better c. Staff document that client's mood is less depressed d. Client agrees to talk with staff if thoughts of self-harm occur |
D. If the client agrees to talk with staff if thoughts of self-harm occur, constant observation for safety can be changed.
When a client reports feeling less depressed, the client has more energy and is at increased risk of self-harm. Although the client's room is safe, the client may feel suicidal and find objects in the environment to hurt himself. |
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A nursing care plan is needed for a patient with bipolar disorder who’s currently in the maintenance phase of the illness. The nurse should know that the focus of the care plan should be:
a. Counseling, and psychoeducation teaching for the client b. Maintain safety, and avoid self-injury c. Maintain medication compliance d. Prevent relapse |
D. the overall outcomes for the maintenance phase focus on prevention of relapse and limitation of severity and duration of future episodes.
In the acute phase, the focus is on maintaining safety and avoiding self-injury. Counseling, psychoeducation, and maintaining medication compliance are the goals focused on the continuation phase. |
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_____ means simultaneously holding two opposing emotions, attitudes, ideas, or wishes toward the same person, situation, or object
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Ambivalence
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A psychotic disorder characterized by delusions, hallucinations, disorganized speech, and catatonic behavior
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Schizophrenia
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Which of the following conditions also occur in people diagnosed with schizophrenia? [select all that apply]
a. Nicotine dependence b. Anxiety c. Depression d. Substance abuse disorders |
All of the above. Substance abuse disorders occur in nearly 50% of persons with schizophrenia. Nicotine dependence rates in schizophrenia range from 70 – 90%. Anxiety and depression co-occur frequently in schizophrenia.
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A nurse in a mental health unit is about to administer antipsychotic medication to a patient with schizophrenia. Which of the following interventions is appropriate for the client regarding the condition?
a. Encourage / increase water intake b. Limit / monitor water intake c. Limit patient interaction with others d. Restraints / seclusion precautions |
B. polydipsia can lead to fatal water intoxication characterized by seemingly insatiable thirst resulting in dangerous intake of water. Factors contributing to excess water intake include dry mouth due to antipsychotic medication, and compulsive behavior
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In the four main symptom groups of schizophrenia, ____ symptoms define the presence of something that is not normally present, while ____ symptoms define the absence of something that should be present but is not.
a. Negative ; positive b. Positive ; negative c. Cognitive ; affective d. Affective ; cognitive |
B. positive symptoms define the presence of something that isn’t normally present (delusions, hallucinations, paranoia) while negative symptoms describe the absence of something that should be present but is not (lack of motivation, anhedonia, apathy)
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Which of the following patient characteristics indicate presence of positive symptoms of schizophrenia?
a. Patient is easily distracted and inattentive b. Patient expresses loss of motivation and blunted affect c. Patient stated “I am the best doctor in here. I can cure everyone” d. Patient shows few recreational interests and physical anergia |
C. positive symptoms of schizophrenia manifests as delusions, hallucinations, and paranoia.
Negative symptoms manifest as blunted affect, anhedonia, asocial, and attention deficits |
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___ describes false, fixed beliefs that can’t be corrected by reasoning
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Delusion
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___ involves perceiving a sensory experience for which no external stimulus exist
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Hallucinations
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During assessment the nurse asked the patient diagnosed with schizophrenia; “When was the last time you ate?” the client quickly replied; “ate a rate on a plate inside a gate, mate, date.” Which alteration of speech is the client experiencing?
a. Clang association b. Neologisms c. Word salad d. Echolalia |
A. clang association is the choice of words based on their sound rather than their meaning, often rhyming and sometimes having a similar beginning sound
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which of the following nursing diagnoses is most appropriate for a patient with schizophrenia experiencing lack of motivation (avolition) and is unable to initiate tasks?
a. Disturbed thought process b. Self-care deficit c. Disturbed sensory perception d. Impaired social interaction |
B. a person showing lack of motivation (avolition) and the inability to initiate tasks show self care deficit, primarily pertaining to patient’s inability to maintain proper hygiene and grooming, and other aspects of daily living
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A mental health nurse is listening to her start-of-shift report when a patient with schizophrenia approached the nurse and told her “The devil is standing beside me and won’t leave me alone” the most appropriate response the nurse should tell patient should be:
a. “There is no one standing beside you. It’s all in your head.” b. “I don’t see the devil standing beside you, but I understand how upsetting that must be for you.” c. “if you have been good and followed the nurse’s orders, the devil wouldn’t have to follow you” d. “You must’ve missed taking your medications because you’re hallucinating again” |
B. hallucinations are real to the person who is experiencing them. The focus of the nurse should be to understand the patient’s experiences and responses. Respond to the patient in a nonthreatening and nonjudgmental manner. Don’t negate the patient’s experience, but offer your own perceptions.
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A mental health nurse is giving his end-of-shift report when a patient with schizophrenia approached the nurse and told him “the doctor is here to see me and he’s come to kill me” the most appropriate response the nurse should tell the patient should be:
a. “It is true the doctor wants to see you, but he wants to talk to you about your treatment. Would you feel more comfortable talking to him in the day room?” b. “Don’t be so silly. Doctors don’t kill their patients” c. “You shouldn’t think badly about your doctor. He’s here to help you” d. “What makes you think that your doctor is here to kill you?” |
A. it is never useful to debate or attempt to dissuade the patient regarding the delusion. Doing so can intensify the retention of irrational beliefs and cause the patient to view you as rejecting or oppositional. However, it is helpful to clarify misguided interpretations and gently suggest, as tolerated, a more reality-based perspective.
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A patient is started on Seroquel, an atypical antipsychotic. Which of the following disadvantages the nurse should discuss with the patient regarding the medication?
a. The medication doesn’t treat negative symptoms (anergia, anhedonia) b. The medication can cause anticholinergic effects (urinary retention, tachycardia) c. The medication can cause metabolic syndrome (weight gain, altered glucose metabolism) d. The medication can cause extrapyramidal side effects (pseudoparkinsonism, tardive dyskinesia) |
C. atypical antipsychotics (Seroquel, Abilify, Zyprexa) diminish negative and positive symptoms of schizophrenia and are often chosen as first-line antipsychotics. One significant disadvantage of the drug is they have a tendency to cause metabolic syndrome which includes weight gain and altered glucose metabolism.
All the other choices pertain to the traditional antipsychotics (Thorazine, Haldol, Prolixin) |
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A client has been receiving antipsychotic medication for 6 weeks. At her clinic appointment she tells the nurse that her hallucinations are nearly gone and that she can concentrate fairly well. She states her only problem is "the flu" that she's had for 2 days. She mentions having a fever and a very sore throat. The nurse should:
a. arrange for the client to have blood drawn for a white blood cell count b. advise the physician that the client should be admitted to the hospital c. suggest that the client take something for her fever and get extra rest d. consider recommending a change of antipsychotic medication |
A. Antipsychotic medications may cause agranulocytosis, the first manifestation of which may be a sore throat and flulike symptoms.
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The purpose for a nurse periodically performing the Abnormal Involuntary Movement Scale (AIMS) assessment on a persistently mentally ill client who has schizophrenia is early detection of:
a. cholestatic jaundice b. pseudoparkinsonism c. tardive dyskinesia d. acute dystonia |
C. An AIMS assessment should be performed periodically on clients who are being treated with antipsychotic medication known to cause tardive dyskinesia.
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Which of the following group of people have the highest prevalence of suicide?
a. 35 year old African American female b. 70 year old African American male c. 70 year old white male d. 35 year old white female |
C. elderly white men over the age of 65 have the highest prevalence of suicide
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Which of the following statements about suicide is true?
a. Suicide rates for men peak after the age of 55; for women, it peaks after 45 b. Male adults aged 65 years or older have the lowest rate of suicide c. Suicide is essentially synonymous with a mental disorder d. suicide risk is 50 times higher among patients with schizophrenia than the general population |
D. patients with schizophrenia are 50 times more at risk for suicide than the general population.
Suicide is not necessarily synonymous with a mental disorder. Suicide rates for men peak after age 45; women after age 55, and male adults aged 65 or older have the highest prevalence of suicide |
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The charge nurse in the unit is doing a primary client assessment when the client mentioned “Life isn’t worth living anymore.” Which of the following should the charge nurse do?
a. Continue on with the assessment b. Ask the client directly if he is thinking or attempting suicide c. Be careful not to mention the idea of suicide d. Refer the client to the psychiatrist or counselor in the unit |
B. Covert references should be made overt. The nurse should directly address any suicidal hints given by the client. Self-destructive ideas are a personal decision.
Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis. |
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A suicide hotline is an example of what level of nursing intervention?
a. Primary b. Secondary c. Tertiary |
B. secondary intervention is treatment of the actual suicide crisis. It is practiced in clinics, hospitals, and on telephone hotlines
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Which of the following environmental guidelines doesn’t minimize suicidal behavior in a mental health unit?
a. Lock all utility rooms, kitchens, adjacent stairwells, and offices b. Assign patient to a private room to facilitate monitoring c. Install unbreakable glass in windows, tamperproof screens or partitions too small to pass through d. Use plastic eating utensils |
B. patients with suicidal tendencies shouldn’t be assigned to a private room, and ensure the door remains open at all times
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If a suicidal client is to be treated outside the hospital, which intervention would be of high priority?
a. Make sure the client has food enough to last for 2 to 3 days b. Have the client identify three people to call if he is overwhelmed by hopelessness c. Arrange for a police visit every 24 hours d. Provide a 1-week supply of antidepressant medication |
B. For suicidal clients treated in the community, establishing a network of individuals to whom the client may turn if the suicidal urge becomes great is important.
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Which assessment statement(s) would be appropriate for a patient who may be suicidal? [select all that apply]
a. “Are you thinking of hurting yourself?” b. “Do you ever think about suicide?” c. “Has it ever seemed like life is not worth living?” d. “If you were to kill yourself, how would you do it?” |
All of the above. When assessing for risk of suicide it is helpful to be direct and open in one’s inquiries. Such questioning will not “give the patient the idea,” and by being frank, the clinician may increase the likelihood that the patient will respond with a similar degree of frankness. Inquiring about ideation, intent, and plans is essential to a suicide assessment.
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The nursing diagnosis; “Risk for suicide r/t feeling overwhelmed and depressed” has been listed for a client with suicidal ideation. Which of the following short term goals is/are most appropriate for the listed nursing diagnosis? [select all that apply]
a. Client will discuss feelings of isolation and loneliness by the end of the week b. Client will identify three positive aspects of self by the end of the week c. Client will immediately seek help when feeling self-destructive d. Client will state that she enjoys doing one new activity with at least one other person by the end of the week |
C. all the other choices are relevant to the nursing diagnosis; “Impaired social interaction r/t feelings of fear and shame AEB avoiding disclosure of issues and feelings with others”
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In planning care for a patient with schizophrenia experiencing delusional thoughts, which is the most important short-term client outcome?
a. Patient will be able to interact without expressing delusional thoughts b. Identify actions to take to prevent relapse c. Create a support network for the client within the community d. Identify at least one symptom management technique |
A. When a client is delusional, interacting without expressing delusional thoughts is an important short-term outcome. As the client gains insight into the symptoms, the client can differentiate experiences with delusions from those that are reality.
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Which side effects are characteristic of atypical antipsychotics?
a. Less incidence of weight gain b. Increased tardive dyskinesia c. Increased extrapyramidal side effects d. Decreased extrapyramidal side effects |
D. Atypical antipsychotics have less extrapyramidal effects.
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One of the long term goals noted for a client with schizophrenia is that the client will not experience delusional thoughts by discharge. Which intervention by the nurse will best assess if the goal is met?
a. Asking the client how she feels b. Observing the client for signs of talking to self c. Talk to the client for at least 20 minutes d. Ask client if the medication is helping her |
C. The nurse should be able to talk to the client without observing the presence of delusional thoughts.
A client who talks to self may be experiencing auditory hallucinations. Asking the client how he feels will not determine if the client is still delusional. Talking to the client about medications will not assess whether or not the long-term goal is met. |
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A client is ordered 50 milligrams of Amoxicillin trihydrate. Available: 125 milligrams per 5 millilitres. How much will you administer?
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2 ml
Solution: 50 mg x (125 mg / 5 ml) = 50 mg x (1 ml / 25 mg) = 2 ml |
