Answer Choices:
a. Offer laxatives, if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
Answer:
A, B, C
Question: A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, “Do I have to keep taking this lithium even though my mood is stable now?” Select the nurse’s most appropriate response.
Answer Choices:
a. “You will be able to stop the medication in approximately 1 month.”
b. “Taking the medication every day helps prevent relapses and recurrences.”
c. “Usually patients take this medication for approximately 6 months after discharge.”
d. “It’s unusual that the health care provider has not already stopped your medication.”
Answer:
B
Question: Which situations qualify as abandonment on the part of a nurse? (Select all that apply.)
Answer Choices:
a. The nurse allows a patient with acute mania to refuse hospitalization without taking further action.
b. The nurse terminates employment without referring a seriously mentally ill patient for aftercare.
c. The nurse calls police to bring a suicidal patient to the hospital after a suicide attempt.
d. The nurse refers a patient with persistent paranoid schizophrenia to community treatment.
e. The nurse asks another nurse to provide a patient’s care because of concerns about countertransference.
Answer:
a. The nurse allows a patient with acute mania to refuse hospitalization without taking further action,
b. The nurse terminates employment without referring a seriously mentally ill patient for aftercare.
Question: A nurse volunteers for a committee that must revise the hospital policies and procedures for suicide precautions. Which resources would provide the best guidance? (Select all that apply.)
Answer Choices:
a. Diagnostic and Statistical Manual of Mental Disorders (fifth edition) (DSM-5)
b. State’s nurse practice act
c. State and federal regulations that govern hospitals
d. Summary of common practices of several local hospitals
e. American Nurses Association Scope and Standards of Practice
Answer:
c. State and federal regulations that govern hospitals, e. American Nurses Association Scope and Standards of Practice
Question: A patient being treated for major depressive disorder has taken 300 mg amitriptyline daily for a year. The patient calls the case manager at the clinic and says, “I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares.” How should the nurse advise the patient?
Answer Choices:
a. “Go to the nearest emergency department immediately.”
b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.”
c. “Take one dose of the antidepressant, and then come to the clinic to see the health care provider.”
d. “Resume taking the antidepressant for 2 more weeks, and then discontinue it again.”
Answer:
C
Question: A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
Answer Choices:
a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Ineffective therapeutic regimen management
Answer:
A
Question: Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?
Answer Choices:
a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
b. Slept 10 hours uninterrupted. Attended craft group; stated “project was a failure, just like me.”
c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.
d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, “I feel tired all the time.”
Answer:
A
Question: A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse should implement what intervention?
Answer Choices:
a. Explain how to manage postural hypotension and educate the patient that side effects go away after several weeks.
b. Tell the patient that the side effects are a minor inconvenience compared with the feelings of depression.
c. Withhold the drug, force oral fluids, and notify the health care provider to examine the patient.
d. Teach the patient how to use pursed-lip breathing.
Answer:
A
Question: A patient diagnosed with major depressive disorder is receiving imipramine 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?
Answer Choices:
a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention
Answer:
D
Question: A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
Answer Choices:
a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.
b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities.
c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet.
d. The patient needs time to reorient himself or herself to a pressured work schedule.
Answer:
A
Question: When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority?
Answer Choices:
a. Allowing the patient to act out his or her feelings
b. Setting limits on the patient’s behavior as necessary
c. Providing verbal instructions to the patient to remain calm
d. Restraining the patient to reduce hyperactivity and aggression
Answer:
B
Question: A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a pool cue in one hand and says, “I’ll protect myself if anyone comes near me.” What is the nurse’s first intervention?
Answer Choices:
a. Telling the patient, “You need to be secluded.”
b. Demanding the patient, “get down from the table.”
c. Clearing the room of all other patients.
d. Assembling staff for a show of force.
Answer:
C
Question: A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?
Answer Choices:
a. Monitor physiological functioning.
b. Provide a subdued environment.
c. Supervise personal hygiene.
d. Observe for mood changes.
Answer:
B
Question: A nurse provided medication education for a patient who is prescribed phenelzine for depression. Which patient behavior indicates effective learning?
Answer Choices:
a. Monitors sodium intake and weight daily.
b. Wears support stockings and elevates the legs when sitting.
c. Consults the pharmacist when selecting over-the-counter medications.
d. Can identify foods with high selenium content, which should be avoided.
Answer:
C
Question: A patient experiencing acute mania has disrobed in the hall three times in 2 hours. What intervention should the nurse implement?
Answer Choices:
a. Place the patient in the seclusion room.
b. Ask the patient if finds clothes bothersome.
c. Tell the patient that others feel embarrassed.
d. Arrange for one-on-one supervision.
Answer:
D
Question: A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. What action should the nurse take?
Answer Choices:
a. Avoid forcing the issue.
b. Bringing up the issue at the community meeting.
c. Calmly telling the patient, “You must bathe daily.”
d. Firmly and neutrally assisting the patient with showering.
Answer:
D
Question: What is the focus of outcome identification for the treatment plan of a patient presenting with grandiose thinking associated with acute mania?
Answer Choices:
a. Maintaining an interest in the environment
b. Developing an optimistic outlook
c. Self-control of distorted thinking
d. Stabilizing the sleep pattern
Answer:
C
Question: A patient with severe depression states, “God is punishing me for my past sins.” What is the nurse’s best response? a. “Why do you think that?” b. “You sound very upset about this.” c. “You believe God is punishing you for your sins?” d. “If you feel this way, you should talk to a member of your clergy.”
Answer Choices:
a. “Why do you think that?”
b. “You sound very upset about this.”
c. “You believe God is punishing you for your sins?”
d. “If you feel this way, you should talk to a member of your clergy.”
Answer:
B
Question: Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive disorder (MDD) as well as one experiencing acute mania?
Answer Choices:
a. Deficient diversional activity
b. Disturbed sleep pattern
c. Fluid volume excess
d. Defensive coping
Answer:
B
Question: A patient’s employment is terminated, and major depressive disorder develops shortly afterward. The patient says to the nurse, “I’m not worth the time you spend with me. I’m the most useless person in the world.” Which nursing diagnosis applies?
Answer Choices:
a. Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity
Answer:
C
Question: Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective?
Answer Choices:
a. “Covers without interrupting; clothing matches; participates in art activities.”
b. “Irritable, suggestible, distractible; napped for 10 minutes in a sitting position.”
c. “Attention span short; writing copious notes; introduces many topics.”
d. “Heavy makeup; seductive toward staff; pressured speech.”
Answer:
A