Health and Healing 4 - exam study weeks 4-6 Questions
With Complete Solutions
A client admitted to the psychiatric unit following a suicide
attempt is diagnosed with major depressive disorder. Which
behavioral symptoms should the nurse expect to assess?
A. Anxiety and unconscious anger
B. Lack of attention to grooming and hygiene
C. Guilt and indecisiveness
D. Expressions of poor self-esteem Correct Answers B. Lack of
attention to grooming and hygiene
Lack of attention to grooming and hygiene is the only behavioral
symptom presented. Depressed clients do not care enough about
themselves to participate in grooming and hygiene.
A client diagnosed with bipolar disorder has been taking lithium
carbonate for one year. The client presents in an emergency
department with a temperature of 101F (38C), severe diarrhea,
blurred vision, and tinnitus. How should the nurse interpret these
symptoms?
A. Symptoms indicate consumption of foods high in tyramine.
B. Symptoms indicate lithium carbonate discontinuation
syndrome.
C. Symptoms indicate the development of lithium carbonate
tolerance.
D. Symptoms indicate lithium carbonate toxicity. Correct
Answers D. Symptoms indicate lithium carbonate toxicity.
,A client diagnosed with Schizophrenia sees you drop off their
lunch tray, they say "I'm not eating that! You're trying to poison
me- all these FBI agents are". How should the nurse respond?
a."I'm not poisoning you! Come try your lunch"
b."I'm not an FBI agent here to poison you"
c."I am a nurse, you're a client in the hospital. I'm not going to
harm you"
d."Why would you think I am trying to poison you?" Correct
Answers c."I am a nurse, you're a client in the hospital. I'm not
going to harm you"
You want to define your role and who they are - never ask 'why'
or use their delusions in your conversations- so don't mention
anything about not being 'fbi' because they can then fixate on
you saying 'fbi' and cause more thoughts
Re-orientate the client, keep calm
A client is diagnosed with bipolar disorder and admitted to an
inpatient psychiatric unit. Which is the priority outcome for this
client?
A. The client will accomplish activities of daily living
independently by discharge.
B. The client will verbalize feelings during group sessions by
discharge.
C. The client will remain safe throughout hospitalization.
D. The client will use problem solving to cope adequately after
discharge. Correct Answers C. The client will remain safe
throughout hospitalization.
,A client with a diagnosis of Borderline Personality Disorder
often exhibits alternating clinging and distancing behaviors. The
most appropriate nursing intervention with this type of behavior
would be to:
a.Encourage the client to establish trust in one staff person, with
whom all therapeutic interaction should take place
b.Secure a verbal contract from the client that she will
discontinue these behaviors
c.Withdraw attention if these behaviors continue
d.Setting clear and consistent boundaries Correct Answers
a.Setting clear and consistent boundaries
A nurse assesses a client suspected of having major depressive
disorder. Which client symptom would eliminate this diagnosis?
A. The client is disheveled and malodorous.
B. The client refuses to interact with others.
C. The client is unable to feel any pleasure.
D. The client has maxed-out charge cards and exhibits
promiscuous behaviors. Correct Answers D. The client has
maxed-out charge cards and exhibits promiscuous behaviors.
A nurse is implementing a one-on-one suicide observation level
with a client diagnosed with major depressive disorder. The
client states, "I'm feeling a lot better so you can stop watching
me. I have taken up too much of your time already." Which is
the best nursing reply?
, A. "I really appreciate your concern but I have been ordered to
continue to watch you."
B. "Because we are concerned about your safety, we will
continue to observe you."
C. "I am glad you are feeling better. The treatment team will
consider your request."
D. "I will forward you request to your psychiatrist because it is
his decision." Correct Answers B. "Because we are concerned
about your safety, we will continue to observe you."
Often suicidal clients resist personal monitoring which impedes
the implementation of a suicide plan. A nurse should continually
observe a client when risk for suicide is suspected.
A nurse reviews the laboratory data of a client suspected of
having major depressive disorder. Which laboratory value would
potentially rule out this diagnosis?
A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL
B. Potassium (K+) level of 4.2 mEq/L
C. Sodium (Na+) level of 140 mEq/L
D. Calcium (Ca2+) level of 9.5 mg/dL Correct Answers A.
Thyroid-stimulating hormone (TSH) level of 6.2 U/mL
The normal range of TSH levels in non-pregnant adult women is
0.5 to 5.0 mIU/L. In women, during the menstruation cycle,
pregnancy, or after menopause, TSH levels may fall slightly
outside the normal range, because of fluctuating levels of
estrogen.
With Complete Solutions
A client admitted to the psychiatric unit following a suicide
attempt is diagnosed with major depressive disorder. Which
behavioral symptoms should the nurse expect to assess?
A. Anxiety and unconscious anger
B. Lack of attention to grooming and hygiene
C. Guilt and indecisiveness
D. Expressions of poor self-esteem Correct Answers B. Lack of
attention to grooming and hygiene
Lack of attention to grooming and hygiene is the only behavioral
symptom presented. Depressed clients do not care enough about
themselves to participate in grooming and hygiene.
A client diagnosed with bipolar disorder has been taking lithium
carbonate for one year. The client presents in an emergency
department with a temperature of 101F (38C), severe diarrhea,
blurred vision, and tinnitus. How should the nurse interpret these
symptoms?
A. Symptoms indicate consumption of foods high in tyramine.
B. Symptoms indicate lithium carbonate discontinuation
syndrome.
C. Symptoms indicate the development of lithium carbonate
tolerance.
D. Symptoms indicate lithium carbonate toxicity. Correct
Answers D. Symptoms indicate lithium carbonate toxicity.
,A client diagnosed with Schizophrenia sees you drop off their
lunch tray, they say "I'm not eating that! You're trying to poison
me- all these FBI agents are". How should the nurse respond?
a."I'm not poisoning you! Come try your lunch"
b."I'm not an FBI agent here to poison you"
c."I am a nurse, you're a client in the hospital. I'm not going to
harm you"
d."Why would you think I am trying to poison you?" Correct
Answers c."I am a nurse, you're a client in the hospital. I'm not
going to harm you"
You want to define your role and who they are - never ask 'why'
or use their delusions in your conversations- so don't mention
anything about not being 'fbi' because they can then fixate on
you saying 'fbi' and cause more thoughts
Re-orientate the client, keep calm
A client is diagnosed with bipolar disorder and admitted to an
inpatient psychiatric unit. Which is the priority outcome for this
client?
A. The client will accomplish activities of daily living
independently by discharge.
B. The client will verbalize feelings during group sessions by
discharge.
C. The client will remain safe throughout hospitalization.
D. The client will use problem solving to cope adequately after
discharge. Correct Answers C. The client will remain safe
throughout hospitalization.
,A client with a diagnosis of Borderline Personality Disorder
often exhibits alternating clinging and distancing behaviors. The
most appropriate nursing intervention with this type of behavior
would be to:
a.Encourage the client to establish trust in one staff person, with
whom all therapeutic interaction should take place
b.Secure a verbal contract from the client that she will
discontinue these behaviors
c.Withdraw attention if these behaviors continue
d.Setting clear and consistent boundaries Correct Answers
a.Setting clear and consistent boundaries
A nurse assesses a client suspected of having major depressive
disorder. Which client symptom would eliminate this diagnosis?
A. The client is disheveled and malodorous.
B. The client refuses to interact with others.
C. The client is unable to feel any pleasure.
D. The client has maxed-out charge cards and exhibits
promiscuous behaviors. Correct Answers D. The client has
maxed-out charge cards and exhibits promiscuous behaviors.
A nurse is implementing a one-on-one suicide observation level
with a client diagnosed with major depressive disorder. The
client states, "I'm feeling a lot better so you can stop watching
me. I have taken up too much of your time already." Which is
the best nursing reply?
, A. "I really appreciate your concern but I have been ordered to
continue to watch you."
B. "Because we are concerned about your safety, we will
continue to observe you."
C. "I am glad you are feeling better. The treatment team will
consider your request."
D. "I will forward you request to your psychiatrist because it is
his decision." Correct Answers B. "Because we are concerned
about your safety, we will continue to observe you."
Often suicidal clients resist personal monitoring which impedes
the implementation of a suicide plan. A nurse should continually
observe a client when risk for suicide is suspected.
A nurse reviews the laboratory data of a client suspected of
having major depressive disorder. Which laboratory value would
potentially rule out this diagnosis?
A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL
B. Potassium (K+) level of 4.2 mEq/L
C. Sodium (Na+) level of 140 mEq/L
D. Calcium (Ca2+) level of 9.5 mg/dL Correct Answers A.
Thyroid-stimulating hormone (TSH) level of 6.2 U/mL
The normal range of TSH levels in non-pregnant adult women is
0.5 to 5.0 mIU/L. In women, during the menstruation cycle,
pregnancy, or after menopause, TSH levels may fall slightly
outside the normal range, because of fluctuating levels of
estrogen.
