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A client has been diagnosed with depersonalization/derealization disorder. Which of the following behaviors should the nurse expect?
- A. Feelings of detachment from one's body
- B. Fear of gaining weight
- C. Paralysis of a limb
- D. Episodes of hypomania
Correct Answer: A
Rationale: Depersonalization/derealization disorder is characterized by feelings of detachment from one's body or surroundings. Individuals with this disorder may feel like they are observing themselves from outside their body or that the world around them is unreal. Therefore, the nurse should expect behaviors such as feelings of detachment from one's body (A). Fear of gaining weight (B) is more indicative of an eating disorder, paralysis of a limb (C) could be related to neurological issues, and episodes of hypomania (D) are associated with mood disorders like bipolar disorder, but not specifically with depersonalization/derealization disorder.
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A client with bipolar disorder is experiencing a depressive episode. Which nursing intervention is most appropriate?
- A. Encourage the client to avoid physical activity.
- B. Encourage the client to engage in social activities.
- C. Encourage the client to participate in group therapy.
- D. Encourage the client to set realistic goals.
Correct Answer: C
Rationale: Encouraging the client to participate in group therapy is the most appropriate nursing intervention for a client with bipolar disorder experiencing a depressive episode. Group therapy provides a supportive environment where the client can share experiences, learn coping strategies, and receive emotional support from peers and mental health professionals. It can help reduce feelings of isolation, improve social skills, and enhance overall well-being. Group therapy also promotes a sense of belonging and understanding, which are essential for individuals dealing with bipolar disorder and depressive symptoms. Choices A, B, and D are not the most appropriate interventions for a client experiencing a depressive episode in bipolar disorder. Encouraging the client to avoid physical activity may worsen their symptoms, promoting social activities may not address the underlying issues effectively, and setting goals may be overwhelming during a depressive episode.
When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?
- A. Restlessness
- B. Rapid heart rate
- C. Sweating
- D. Dry mouth
Correct Answer: B
Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.
During a community education session on mental health, which statement about stigma and mental illness is correct?
- A. Stigma has no impact on treatment outcomes.
- B. Stigma can prevent individuals from seeking treatment.
- C. Stigma is only a problem in developing countries.
- D. Stigma related to mental illness is decreasing significantly worldwide.
Correct Answer: B
Rationale: The correct answer is B: 'Stigma can prevent individuals from seeking treatment.' Stigma surrounding mental illness can create barriers for individuals seeking treatment. It can lead to feelings of shame, fear of judgment, and discrimination, which may deter individuals from accessing the necessary support and care they need. Choices A, C, and D are incorrect. Stigma does have a significant impact on treatment outcomes by discouraging individuals from seeking help, it is not limited to developing countries but is a global issue, and unfortunately, stigma related to mental illness is still prevalent worldwide, although efforts are being made to reduce it.
A client diagnosed with post-traumatic stress disorder (PTSD) is being assessed by a healthcare professional. Which symptom would the healthcare professional expect the client to exhibit?
- A. Delusions of grandeur
- B. Hypervigilance
- C. Obsessive-compulsive behaviors
- D. Periods of excessive sleeping
Correct Answer: B
Rationale: In individuals with post-traumatic stress disorder (PTSD), hypervigilance is a common symptom. Hypervigilance refers to a state of increased alertness, awareness, and sensitivity to potential threats or danger. This heightened state of vigilance can manifest as being easily startled, having difficulty relaxing or sleeping, and constantly scanning the environment for signs of danger. It is an adaptive response to the trauma experienced and can significantly impact the individual's daily functioning. The other options are not typically associated with PTSD. Delusions of grandeur are more commonly seen in certain psychiatric disorders like bipolar disorder or schizophrenia. Obsessive-compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD), not PTSD. Periods of excessive sleeping may be seen in conditions like depression, but they are not a hallmark symptom of PTSD.
A client has been prescribed fluoxetine (Prozac). What information should the nurse include in discharge teaching?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication only when feeling depressed.
- D. Report any unusual side effects to the healthcare provider.
Correct Answer: B
Rationale: The correct answer is to advise the client to avoid drinking alcohol while taking fluoxetine (Prozac) due to potential interactions. Alcohol consumption can increase the risk of certain side effects and may reduce the effectiveness of the medication. Choice A is incorrect because fluoxetine can be taken with or without food. Choice C is incorrect as fluoxetine is usually taken daily regardless of the client's mood. Choice D is not the priority teaching point; while reporting side effects is important, avoiding alcohol is critical due to the potential interactions.