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A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?
- A. If you do not get out of bed, you will not receive your meal.'
- B. You really need to follow the rules of the unit and get out of bed.'
- C. I will help you sit up and get your slippers on.'
- D. You should rest in bed until you feel able to take part in unit activities.'
Correct Answer: C
Rationale: Threatening to withhold meals is coercive. Enforcing rules dismisses the client’s fatigue. Offering help supports the client’s engagement without pressure, addressing depression’s lethargy. Encouraging rest may reinforce withdrawal, worsening depression.
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Which medication would the nurse expect to be prescribed for a client with moderate stages of Alzheimer's disease?
- A. Risperidone (Risperdal)
- B. Alprazolam (Xanax)
- C. Donepezil (Aricept)
- D. Haloperidol (Haldol)
Correct Answer: C
Rationale: Risperidone is an antipsychotic used for behavioral issues in dementia, not cognitive decline. Alprazolam is an anxiolytic, not indicated for Alzheimer’s cognitive symptoms. Donepezil is a cholinesterase inhibitor commonly prescribed to improve cognition and slow symptom progression in moderate Alzheimer’s. Haloperidol, an antipsychotic, treats agitation but doesn’t enhance cognition and has higher side effect risks.
A nurse is caring for a client who has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first?
- A. Tell the client you will remain with her.
- B. Take the client to a quiet room.
- C. Ask the client what precipitated this anxiety
- D. Offer the client a prescribed anxiety medication
Correct Answer: A
Rationale: Reassuring presence stabilizes the client emotionally, addressing immediate distress. A quiet room helps but follows reassurance. Asking about triggers is secondary to calming the client. Medication may be needed, but support comes first.
A client is given the diagnosis of generalized anxiety disorder and is prescribed a benzodiazepine. The client should be instructed on which of the following?
- A. Monthly laboratory tests are needed to monitor drug level.
- B. Foods that contain tyramine should be avoided
- C. Benzodiazepines do not cause physical dependence.
- D. Benzodiazepines and alcohol can be dangerous
Correct Answer: D
Rationale: Lab tests aren’t routine for benzodiazepines. Tyramine avoidance applies to MAOIs, not benzodiazepines. Benzodiazepines can cause dependence, so that’s false. Combining benzodiazepines with alcohol increases CNS depression, posing risks like respiratory failure, making it critical to instruct the client on this danger.
A client describes flashbacks of a terrifying car crash in which he saw his best friend die. Which disorder should the nurse suspect in this situation?
- A. Panic disorder
- B. Obsessive-compulsive disorder
- C. Posttraumatic stress disorder
- D. Agoraphobia
Correct Answer: C
Rationale: Panic disorder involves unexpected and repeated episodes of intense fear, often without a specific trigger, and isn’t typically linked to flashbacks. Obsessive-compulsive disorder is characterized by unwanted repeated thoughts (obsessions) and actions (compulsions), not trauma-related flashbacks. PTSD involves re-experiencing a traumatic event through flashbacks and nightmares, directly matching the client’s symptoms of reliving the car crash. Agoraphobia is an anxiety disorder involving fear of places or situations that might cause panic, not tied to specific traumatic memories.
Which of the following is a physical clinical finding of depression in older adults?
- A. Increased anxiety
- B. Slowed memory
- C. Slowed intellect
- D. Headache
Correct Answer: D
Rationale: Increased anxiety is a psychological symptom, not a physical finding, though it may accompany depression. Slowed memory and intellect are cognitive symptoms related to depression’s impact on thinking, not physical manifestations. Physical symptoms of depression can include changes in sleep, appetite, or pain, such as headaches, which are commonly reported in older adults as a somatic expression of the disorder.