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A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?
- A. Inability to carry out a simple task
- B. Client reports auditory hallucinations
- C. Moves quickly from one idea to the next
- D. Client expresses illusions of grandeur
Correct Answer: A
Rationale: The correct answer is A: Inability to carry out a simple task. During a depressive episode in bipolar disorder, individuals often experience cognitive impairment, including difficulty concentrating and making decisions. This can lead to an inability to carry out simple tasks. Choices B, C, and D are more indicative of symptoms seen in manic episodes, such as auditory hallucinations (B), racing thoughts (C), and grandiosity (D). By understanding the characteristic symptoms of bipolar disorder episodes, the nurse can appropriately assess and provide interventions for the client.
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A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?
- A. "Are you not happy with your treatment?"
- B. "We can provide a copy of your records, but the therapist's notes are not included."
- C. "Why are you interested in seeing your therapist's notes?"
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: B
Rationale: The correct answer is B because therapist's notes are considered privileged information and are not typically included in a client's medical records. Providing these notes could compromise the therapeutic relationship and confidentiality. Option A is incorrect as it assumes the client is unhappy with treatment. Option C is inappropriate as it questions the client's motivation. Option D is incorrect as it dismisses the client's request without proper justification. Options E, F, and G are not provided, but B is the most appropriate response in this scenario.
A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps prevent withdrawal symptoms in clients with opioid use disorder by reducing cravings and preventing withdrawal symptoms without causing euphoria. Disulfiram (B) is used for alcohol use disorder, Naloxone (C) is an opioid antagonist used for opioid overdose reversal, and Bupropion (D) is an antidepressant that is not indicated for opioid withdrawal. By choosing Methadone, the nurse is providing appropriate pharmacological support for the client's opioid use disorder.
A nurse is providing teaching to a client who has generalized anxiety disorder about strategies to manage anxiety. Which of the following should the nurse include? (Select all that apply)
- A. Progressive muscle relaxation
- B. Journaling
- C. Avoiding stressful situations
- D. Deep breathing exercises
- E. Drinking caffeinated beverages
Correct Answer: A,B,D
Rationale: The correct strategies for managing anxiety include A: Progressive muscle relaxation, B: Journaling, and D: Deep breathing exercises. Progressive muscle relaxation helps reduce muscle tension and promote relaxation. Journaling allows the client to express emotions and thoughts, reducing stress. Deep breathing exercises help calm the nervous system and reduce anxiety symptoms.
Avoiding stressful situations (C) is not a feasible long-term solution as it may limit the client's ability to cope with anxiety triggers. Drinking caffeinated beverages (E) can actually worsen anxiety symptoms due to the stimulant effect.
A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse expect? (Select all that apply)
- A. Anhedonia
- B. Insomnia
- C. Weight gain
- D. Flight of ideas
- E. Feelings of worthlessness
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Anhedonia is a key feature of major depressive disorder characterized by the inability to feel pleasure. Insomnia commonly occurs due to disrupted sleep patterns. Feelings of worthlessness are typical in depression due to negative self-perception. Weight gain is less common in major depressive disorder, typically weight loss is more prevalent. Flight of ideas is not a typical finding in major depressive disorder, as it is more associated with manic episodes in bipolar disorder.
A nurse is admitting a client who has dementia to a long-term care facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings?
- A. Projection
- B. Perseveration
- C. Agnosia
- D. Confabulation
Correct Answer: D
Rationale: The correct answer is D: Confabulation. Confabulation is the creation of false memories or distortion of actual memories without the intention to deceive. In this scenario, the client is not intentionally lying, but rather recalling a memory that did not occur. This is common in individuals with dementia. Projection (A) involves attributing one's thoughts or feelings to someone else. Perseveration (B) is the persistent repetition of a response. Agnosia (C) is the inability to recognize familiar objects or people. In this case, the client's statement aligns most closely with confabulation, making it the correct choice.