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A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment.
- A. Are there any things going on in your life that would cause you to consider suicide?'
- B. What are your beliefs about a persons right to take his or her own life?'
- C. Do you think you are vulnerable to developing a depressed mood?'
- D. If you felt suicidal, would you tell someone about your feelings?'
Correct Answer: B
Rationale: This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.
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A client with a borderline personality disorder tells the nurse, 'My doctor tells me there's something wrong with the hard wiring of my brain, and that's why I'm so impulsive and get so many mood swings. He said he's going to prescribe some medication.' Being aware of current practice guidelines, the nurse will prepare a teaching plan for:
- A. Lithium
- B. Fluoxetine
- C. Lorazepam
- D. Haloperidol
Correct Answer: B
Rationale: The correct answer is B: Fluoxetine. In the context of borderline personality disorder, fluoxetine, a selective serotonin reuptake inhibitor (SSRI), is often used to manage symptoms such as mood swings and impulsivity. SSRIs help regulate serotonin levels in the brain, which can improve mood stability and reduce impulsive behaviors.
- A: Lithium is typically used for bipolar disorder, not borderline personality disorder.
- C: Lorazepam is a benzodiazepine used for anxiety or panic disorders, not specific to treating symptoms of borderline personality disorder.
- D: Haloperidol is an antipsychotic medication used for psychosis, not typically indicated for managing impulsivity or mood swings in borderline personality disorder.
The first step in the treatment of sleep disorders is to:
- A. Teach prevention.
- B. Give hypnotics for sleep.
- C. Evaluate sleeping patterns.
- D. None of the above.
Correct Answer: C
Rationale: The correct answer is C: Evaluate sleeping patterns. This is the first step in treating sleep disorders because it helps identify the underlying causes and specific nature of the disorder. By understanding the patterns, triggers, and behaviors related to sleep, healthcare providers can tailor effective treatment plans. Choice A (Teach prevention) is incorrect as evaluation comes before prevention strategies. Choice B (Give hypnotics for sleep) is incorrect as medication should be considered only after thorough evaluation. Choice D (None of the above) is incorrect as evaluating sleeping patterns is crucial for effective treatment.
The nurse caring for a school-age child who has been sexually abused by a close family member realizes that the child may resist disclosing the experience of being sexually abused because the child:
- A. Realizes that repeated questioning by others will occur
- B. Fears being blamed or disbelieved
- C. Fears becoming an object of pity at school
- D. Is embarrassed about facing family members
Correct Answer: B
Rationale: The correct answer is B: Fears being blamed or disbelieved. This is because children who have been sexually abused often fear that they will not be believed or may be blamed for what happened. This fear can prevent them from disclosing the abuse. Choice A is incorrect because repeated questioning may not be the primary reason for the child's resistance. Choice C is incorrect because the child's fear of being pitied at school is not typically a main concern when disclosing sexual abuse. Choice D is incorrect because embarrassment about facing family members may be a factor, but the fear of blame or disbelief is usually a more significant barrier to disclosure in cases of sexual abuse.
Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? Select one tha does not apply.
- A. Lately I have had a lot of aches and pains and just havent felt very well.
- B. People are in and out of my room all day and all night taking my things.
- C. Dont ask me to eat. I cant because my stomach is upset all the time.
- D. Im eating more than usual, and I am sleeping about 6 hours a night.
Correct Answer: D
Rationale: Somatic symptoms (A), delusions of persecution (B), and nihilistic delusions (C) are common in late-onset depression, warranting assessment. Increased appetite and contentment (D, E) do not suggest depression.
Which assessment findings would be expected for a patient diagnosed with bipolar I disorder?
- A. Rapid cycling
- B. Major depression and acute mania
- C. Major depression and/or hypomania
- D. Hypomania and/or minor depression
Correct Answer: B
Rationale: Step 1: Bipolar I disorder involves episodes of acute mania, which is characterized by elevated mood, increased energy, and impulsivity.
Step 2: Major depression can also occur in bipolar I, as patients may experience depressive episodes.
Step 3: Therefore, choice B (Major depression and acute mania) is the correct answer.
Summary: Choice A is incorrect because rapid cycling refers to frequent mood shifts, not specific to bipolar I. Choice C is incorrect as hypomania is characteristic of bipolar II, not bipolar I. Choice D is incorrect as minor depression is not a typical feature of bipolar I disorder.