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A client with major depression is experiencing a disturbed sleep pattern. What nursing intervention will help the client to get maximum sleep during the night?
- A. Acknowledge the client's feeling of despair.
- B. Encourage active exercise before bedtime.
- C. Encourage the client to go to bed early.
- D. Keep the client busy during the day.
Correct Answer: D
Rationale: The nurse should keep the client busy during the day and discourage the client from going to bed early. Left alone, depressed clients are likely to become more vegetative (i.e., they withdraw by sleeping). The nurse should also encourage active exercise during the day but not before bedtime. Exercise relieves anxiety but it may cause stimulation when performed at night. Recognizing a client's mood demonstrates that the nurse has noticed the person and is perceptive but will not help a client with depression in this situation.
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The nurse is caring for a middle-aged client prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect of medication therapy leads to the most common cause of noncompliance?
- A. Hypertension
- B. Dizziness
- C. Hallucinations
- D. Sexual dysfunction
Correct Answer: D
Rationale: When taking a selective serotonin reuptake inhibitor, the nurse must instruct on the most common side effect, which is sexual dysfunction. Unfortunately, sexual dysfunction (reduced desire for sex, erectile and ejaculatory dysfunction, and the inability to orgasm) is a frequent and undesirable side effect that leads to noncompliance in medication regimen. The other side effects are not associated with use of SSRIs.
Which nursing consideration is most important when administering medications to a suicidal client?
- A. Do not leave any syringe unattended.
- B. Watch the client place all pills in the mouth.
- C. View the inside of the mouth to make sure that all medications are swallowed.
- D. Remove all medications and medication administration equipment from client area.
Correct Answer: C
Rationale: It is most important for the nurse to view the inside of the mouth when administering medications. This is done by inspecting the client's mouth and under the tongue because clients may 'cheek' medications to stockpile and use the medications. Not leaving syringes unattended, watching the client place the pills in their mouth, and removing all medications and equipment are all appropriate nursing actions, but the most important is not allowing the opportunity for the client to overdose on medications.
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.
The nurse is completing a medication history for a client diagnosed with bipolar disorder. When assessing the medications, which medication classification is noted as an adjunct to lithium therapy?
- A. Antidiabetics
- B. Antihypertensives
- C. Anticonvulsants
- D. Antianginals
Correct Answer: C
Rationale: Anticonvulsant therapy may be co-prescribed for a brief period to sedate the client and relieve bizarre thought processes faster than monotherapy with lithium. Anticonvulsants enhance the action of gamma-aminobutyric acid (GABA) in much the same way that benzodiazepines reduce anxiety and they are believed to inhibit glutamate.
The nurse is caring for a client diagnosed with seasonal affective disorder (SAD). When caring for the client, at which time of the year does the nurse limit nursing interventions due to an uplifting of mood?
- A. September/October
- B. February/March
- C. April/May
- D. December/January
Correct Answer: C
Rationale: Clients experience an uplifting of mood during the springtime in the months of April/May. During this time, daylight becomes longer. As the mood improves, fewer nursing interventions including phototherapy are needed. As days shorten in fall, the client's mood may begin to worsen until it reaches its lowest point in the dark winter months.