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An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess?
- A. Restlessness, short attention span, hyperactivity
- B. Physical aggressiveness, low stress tolerance disregard for the rights of others
- C. Deterioration in social functioning, excessive anxiety and worry, bizarre behavior
- D. Sadness, poor appetite and sleeplessness, loss of interest in activities
Correct Answer: B
Rationale: Physical aggressiveness, low stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders. Restlessness, short attention span, and hyperactivity are typical behaviors in a client with attention deficit hyperactivity disorder. Deterioration in social functioning, excessive anxiety and worry and bizarre behaviors are typical in schizophrenic disorders. Sadness, poor appetite, sleeplessness, and loss of interest in activities are behaviors commonly seen in depressive disorders.
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A mother telephones an adult psychiatric and mental health nurse practitioner to report that her 13-year-old son has been unusually active, irritable, and unable to sleep for more than a few hours each night. The adolescent has been diagnosed with a major depressive disorder and has been taking fluoxetine (Prozac) for six weeks. The nurse practitioner is most concerned about the possibility that:
- A. a therapeutic level of the drug has not been reached.
- B. an addition of hypnotic medication is warranted.
- C. the adolescent has been misdiagnosed.
- D. the adolescent is experiencing side effects.
Correct Answer: C
Rationale: Symptoms of hyperactivity, irritability, and sleeplessness suggest mania, indicating a possible bipolar disorder misdiagnosed as depression. Fluoxetine can trigger mania in bipolar patients, making misdiagnosis the primary concern over levels , hypnotics , or side effects .
Prior to administering chlorpromazine (Thorazine) to an agitated client, the nurse should:
- A. Assess skin color and sclera
- B. Assess the radial pulse
- C. Take the client's blood pressure
- D. Ask the client to void
Correct Answer: C
Rationale: Because chlorpromazine (Thorazine) can cause a significant hypotensive effect (and possible client injury), the nurse must assess the client's blood pressure (lying, sitting, and standing) before administering this drug. If the client had taken the drug previously, the nurse would also need to assess the skin color and sclera for signs of jaundice, a possible drug side affect; however, based on the information given here, there is no evidence that the client has received chlorpromazine before. Although the drug can cause urine retention, asking the client to avoid will not alter this anticholinergic effect.
For 12 years, a 65-year-old patient with bipolar affective disorder has been treated with lithium (Eskalith) 900 mg daily. When oral hydrochlorothiazide (HCTZ) 12.5 mg daily is added for hypertension, the patient develops nausea, vomiting, ataxia, and muscle weakness and the patient's serum lithium level is $2.0 \mathrm{mEq} / \mathrm{L}$. The interaction of the lithium and the thiazide diuretic has induced:
- A. hypokalemia.
- B. hyponatremia.
- C. increased renal clearance of lithium.
- D. reduced renal clearance of lithium.
Correct Answer: D
Rationale: Thiazide diuretics reduce renal clearance of lithium, leading to accumulation and toxicity (level >1.5 mEq/L), as evidenced by the symptoms and elevated level. Hypokalemia and hyponatremia are not directly caused by this interaction, and clearance is not increased .
Marie, age 56, is the mother of five children. Her youngest child, who had been living at home and attending the local college, recently graduated and accepted a job in another state. Marie has never worked outside the home and has devoted her life to satisfying the needs of her husband and children. Since the departure of her last child from home, Marie has become increasingly dependent. Her husband is very concerned and takes her to the local mental health center. What is this type of crisis called?
- A. dispositional crisis
- B. crisis of anticipated life transitions
- C. psychiatric emergency
- D. crisis resulting from traumatic stress
Correct Answer: B
Rationale: This is an anticipated life transition crisis, as Marie faces the expected yet challenging empty nest phase.
Which method would a nurse use to determine a client's potential risk for suicide?
- A. Wait for the client to bring up the subject of suicide.
- B. Observe the client's behavior for cues of suicide ideation.
- C. Question the client directly about suicidal thoughts.
- D. Question the client about future plans.
Correct Answer: C
Rationale: Directly questioning a client about suicide is important to determine suicide risk. The client may not bring up this subject for several reasons, including guilt regarding suicide, wishing not to be discovered, and his lack of trust in staff. Behavioral cues are important, but direct questioning is essential to determine suicide risk. Indirect questions convey to the client that the nurse is not comfortable with the subject of suicide and, therefore, the client may be reluctant to discuss the topic.