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During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse?
- A. Do you think you could sit still for a few minutes so we can talk?
- B. How are you ever going to get any rest if you keep that music on?
- C. Let's go to the conference room and talk for a while.
- D. Turn the radio down so we can hear ourselves talk.
Correct Answer: C
Rationale: Redirecting to a quieter environment reduces stimuli, promoting calmness and aiding rest.
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A client who has been discharged home on Celexa (citalopram) calls the nurse complaining that the medication causes her to feel too drowsy. The nurse should make which of the following suggestions?
- A. Make an appointment to change to a different medication.
- B. Take the medication at night.
- C. Be patient while this early side effect subsides.
- D. Skip a dose if drowsiness is excessive.
Correct Answer: B
Rationale: Taking citalopram at night minimizes daytime drowsiness, a common side effect, improving adherence.
The wife of a client with bipolar disorder calls the nurse expressing distress about recent spending. The nurse's action would be considered
- A. inappropriate; the nurse should not give advice to the wife.
- B. inappropriate; the husband has the legal right to spend personal money.
- C. appropriate; the wife is responsible for the husband's actions since he has a mental illness.
- D. appropriate; the wife needs support in setting boundaries.
Correct Answer: D
Rationale: Supporting the wife in setting boundaries is appropriate, as it empowers her to manage the client's manic behavior.
Which time periods during antidepressant therapy are persons most likely to commit suicide? Select all that apply.
- A. After starting antidepressant therapy but not having reached the therapeutic level
- B. After having reached the therapeutic level of antidepressants and maintained it for several years
- C. If the client has made a choice to discontinue antidepressant therapy without medical supervision and is becoming gradually more depressed
- D. If the client does not adhere to the medication regimen and takes antidepressant medications irregularly
- E. Prior to initiating antidepressant therapy but before the depression results in lack of energy
Correct Answer: A,C,D,E
Rationale: Suicide risk is highest when energy increases before mood stabilizes, or during untreated or poorly managed depression.
A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply.
- A. Weigh self weekly at the same time of day.
- B. Drink a 2-L bottle of decaffeinated fluid daily.
- C. Do not alter dietary salt intake.
- D. See the doctor if you get the flu.
- E. Restrict involvement in intense exercise.
Correct Answer: B,C,D
Rationale: Maintaining fluid intake, stable salt levels, and monitoring for illness prevent lithium toxicity and ensure therapeutic levels.
A client who is depressed states, 'I think my family would be better off without me. They don't need to worry.' Which would be the most appropriate response by the nurse?
- A. Are you planning to commit suicide?
- B. What do you think they are worried about?
- C. You don't mean that. Your family loves you.
Correct Answer: A
Rationale: Directly asking about suicidal plans addresses potential ideation, ensuring safety and opening further assessment.