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A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
- A. Significant change in weight
- B. Hyperexcitability
- C. Exaggerated response to stimuli
- D. Attention-seeking behavior
Correct Answer: A
Rationale: The correct answer is A: Significant change in weight. In major depressive disorder (MDD), clients commonly experience appetite changes, leading to weight gain or weight loss. This is due to disturbances in their eating patterns. Weight changes can be a result of decreased interest in food or emotional eating. This is a key symptom to monitor in clients with MDD. Hyperexcitability (B), exaggerated response to stimuli (C), and attention-seeking behavior (D) are not typical findings in clients with MDD. Hyperexcitability and exaggerated response to stimuli are more often associated with conditions like anxiety disorders, while attention-seeking behavior is more commonly seen in personality disorders.
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A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.
A nurse is planning discharge for a client who has borderline personality disorder. Which of the following interventions should be included for this client?
- A. Dialectical behavior therapy
- B. Behavioral contract
- C. Milieu therapy
- D. Safety plan
Correct Answer: D
Rationale: The correct answer is D: Safety plan. For a client with borderline personality disorder, a safety plan is crucial to prevent self-harm or suicidal behaviors. This intervention helps the client identify triggers, coping strategies, support resources, and steps to take in a crisis. A: Dialectical behavior therapy is a comprehensive treatment, not just a discharge plan. B: Behavioral contract may not address the immediate safety concerns. C: Milieu therapy focuses on the therapeutic environment, not individual discharge planning.
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
- A. Watching a video with a group in the day room
- B. Walking with the nurse in the courtyard
- C. Participating in a basketball game in the gym
- D. Joining a group discussion about a local election
Correct Answer: B
Rationale: The correct answer is B: Walking with the nurse in the courtyard. During the manic phase, individuals with bipolar disorder may have high energy levels and increased impulsivity. Walking in the courtyard with the nurse provides a safe outlet for physical activity and helps to channel excess energy in a constructive manner. This activity also allows for one-on-one interaction, which can help the client focus and reduce boredom. Other options like watching a video with a group or participating in a basketball game may be too stimulating and could exacerbate manic symptoms. Joining a group discussion about a local election might be overwhelming and less effective in managing the client's energy level and attention.
A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. "Tell me about the concerns that you have regarding your relationship."
- B. "You should try to see your partner’s point of view before your own."
- C. "We could develop a plan for how to talk about this with your partner."
- D. "Relationship difficulties are stressful and require effort to resolve."
Correct Answer: B
Rationale: The correct answer is B. This statement implies a bias towards the partner's perspective, potentially invalidating the client's feelings. The nurse should prioritize understanding the client's concerns first. A is correct as it encourages open communication. C shows proactive problem-solving. D acknowledges the challenges of resolving relationship issues.
A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?
- A. The client's spouse reports that the client has recently gained weight.
- B. The client is dressed in all black.
- C. The client responds to questions with disorganized speech.
- D. The client reports that voices are telling him to write a novel.
Correct Answer: C
Rationale: The correct answer is C because disorganized speech is a key symptom of acute mania in bipolar disorder. Disorganized speech is characterized by incoherent, rapid, and tangential responses, reflecting the racing thoughts and pressured speech commonly seen in manic episodes. This symptom is indicative of a manic state, which is a defining feature of bipolar disorder. Choices A, B, and D are incorrect because they do not directly relate to the diagnostic criteria for acute mania. Weight gain, clothing color choice, and auditory hallucinations are not specific to mania and could be present in other mental health conditions.