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A client with bipolar disorder is having a disturbed thought process. What nursing intervention can help the client to be oriented and accurately perceive circumstances surrounding admission?
- A. Provide ample information.
- B. Support the client when in delusion.
- C. Reduce distracting stimuli.
- D. Offer a large-music activity.
Correct Answer: C
Rationale: The nurse should reduce distracting stimuli such as noise and stimulation. External stimuli potentiate client's internal activity. The nurse should not provide ample information at once, but rather should provide information in small amounts, using brief sentences. Brief discussion accommodates short attention span. The nurse should also present reality when the client is delusional and should not support the delusion of the client. Failing to present reality reinforces that the client's delusions are real. Exercise releases energy and reduces the potential for an angry outburst. It will not help a client with disturbed thought processes to be oriented.
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A nurse is caring for a client newly admitted to the emergency department. The nurse obtains the following vital signs: temperature, 101.6?°F; pulse rate, 92 beats/minute; respiratory rate, 28 breaths/minute; and blood pressure, 160/90 mmHg. The client appears disheveled and disoriented. Upon physical assessment, the nurse notes restlessness and muscle spasms with rigidity. Which documented finding in the health history is evaluated as a potential causative factor?
- A. Mixing antibiotics with psychotherapeutic medications
- B. Changing from one psychotherapeutic to another
- C. Initiating psychotherapeutic drug therapy
- D. Combining dairy products with psychotherapeutics
Correct Answer: B
Rationale: Serotonin syndrome is a potentially life-threatening condition that results from elevated levels of serotonin in the blood secondary to drug therapy. When reviewing the client's medication history and relating the symptoms assessed, the nurse relates the client's status with changing from one psychotherapeutic to another psychotherapeutic medication as a potential causative factor. There is no correlation from the client symptoms to combining antibiotic therapy with psychotherapeutics, initiating psychotherapeutics, or combining dairy products with psychotherapeutics.
The nurse is instructing a client in treatment options often provided to resolve clinical depression. Which option does the nurse instruct as producing a brief, generalized seizure?
- A. Vagal nerve stimulation
- B. Electroconvulsive therapy
- C. Deep brain stimulation
- D. Transcranial magnetic stimulation
Correct Answer: B
Rationale: The nurse is correct to instruct that during electroconvulsive therapy, an electrical stimulation produces brief, generalized seizures. Vagal nerve stimulation is used to treat epilepsy. Deep brain stimulation is used to treat Parkinson disease. Transcranial magnetic stimulation does not produce generalized seizures.
The nurse is providing instruction to a community class regarding seasonal affective disorder (SAD). Which gland and hormone would the nurse stress is responsible?
- A. Thyroid gland and thyroxin
- B. Pineal gland and melatonin
- C. Pancreas and insulin
- D. Pituitary gland and oxytocin
Correct Answer: B
Rationale: The hypothalamus relays the light-sensing data from the sun to the pineal gland. The pineal gland regulates the hormone melatonin. Melatonin also affects the regulation of serotonin, which affects mood.
The nurse is admitting a client to a mental health clinic following a recent suicide attempt and hospitalization. In assessing the client's status, which question is most helpful?
- A. How are you currently feeling?
- B. What made you decide to commit suicide?
- C. Do you have a suicide plan or thoughts of harming yourself?
- D. What method did you choose for your suicide attempt?
Correct Answer: C
Rationale: In assessing the client's status, it is best to evaluate suicide risk factors. A client who is at the highest risk for suicide is the client who verbalizes a desire to end life and has a plan. The other questions are relevant but not the best question for gaining essential information.
Administering an MAOI with food containing tyramine may develop a potentially fatal condition known as which of the following?
- A. Psychosis
- B. Serotonin syndrome
- C. Hypertensive crisis
- D. Hallucinations
Correct Answer: C
Rationale: When a MAOI is combined with foods containing tyramine, another monoamine, clients are likely to develop a potentially fatal hypertensive crisis, with symptoms such as elevated blood pressure and palpitations.