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The nurse is admitting a client to a mental health clinic following a recent suicide attempt and hospitalization. In assessing the client's status, which question is most helpful?
- A. How are you currently feeling?
- B. What made you decide to commit suicide?
- C. Do you have a suicide plan or thoughts of harming yourself?
- D. What method did you choose for your suicide attempt?
Correct Answer: C
Rationale: In assessing the client's status, it is best to evaluate suicide risk factors. A client who is at the highest risk for suicide is the client who verbalizes a desire to end life and has a plan. The other questions are relevant but not the best question for gaining essential information.
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The nurse is caring for a client who reports 'not feeling very well.' When asking the client for specific symptoms, the client is vague with details but does state feeling better when the sun is shining. With this information, the nurse would document which disorder as a possibility?
- A. Major depression
- B. Seasonal affective disorder
- C. Bipolar disorder
- D. Reactive depression
Correct Answer: B
Rationale: The nurse would document seasonal affective disorder as a possibility based on the comments of feeling better when there is sunlight. The other options do not relate to sunlight or time of the year.
Anticonvulsants enhance which neurotransmitter in clients diagnosed with bipolar disorder?
- A. Serotonin
- B. Dopamine
- C. GABA
- D. Acetylcholine
Correct Answer: C
Rationale: Anticonvulsants may achieve their therapeutic effects by enhancing the action of GABA in much the same way that benzodiazepines reduce anxiety. Anticonvulsants do not enhance serotonin, dopamine, or acetylcholine.
The nurse is instructing a client in treatment options often provided to resolve clinical depression. Which option does the nurse instruct as producing a brief, generalized seizure?
- A. Vagal nerve stimulation
- B. Electroconvulsive therapy
- C. Deep brain stimulation
- D. Transcranial magnetic stimulation
Correct Answer: B
Rationale: The nurse is correct to instruct that during electroconvulsive therapy, an electrical stimulation produces brief, generalized seizures. Vagal nerve stimulation is used to treat epilepsy. Deep brain stimulation is used to treat Parkinson disease. Transcranial magnetic stimulation does not produce generalized seizures.
The nurse is employed in a pediatric mental health clinic. Which statement made by the client is an indication of a clinical effect of selective serotonin reuptake inhibitors (SSRI)?
- A. I have gained 25 lb in the last year.
- B. I feel that I am so sleepy all of the time.
- C. No one cares about me. I just want to die.
- D. I have a difficult time concentrating.
Correct Answer: C
Rationale: In the pediatric client, clinical evidence has stated an ominous link between SSRI use and an increased risk of suicidal thoughts and behavior. Some side effects of medication use include nausea, weight loss, insomnia, nervousness, tremor, and headache.
A client with bipolar disorder is having a disturbed thought process. What nursing intervention can help the client to be oriented and accurately perceive circumstances surrounding admission?
- A. Provide ample information.
- B. Support the client when in delusion.
- C. Reduce distracting stimuli.
- D. Offer a large-music activity.
Correct Answer: C
Rationale: The nurse should reduce distracting stimuli such as noise and stimulation. External stimuli potentiate client's internal activity. The nurse should not provide ample information at once, but rather should provide information in small amounts, using brief sentences. Brief discussion accommodates short attention span. The nurse should also present reality when the client is delusional and should not support the delusion of the client. Failing to present reality reinforces that the client's delusions are real. Exercise releases energy and reduces the potential for an angry outburst. It will not help a client with disturbed thought processes to be oriented.