Nokea
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.
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Which observation(s) is helpful in determining a client's mood? Select all that apply.
- A. Client appearance
- B. Body language
- C. Speech
- D. Energy level
- E. Work history
Correct Answer: A,B,C,D
Rationale: The nurse can gather observational data using the assessment skill of inspection. Client appearance that is disheveled indicates signs of personal neglect. Body language may indicate evidence of anxiety, anger, or depression. Pace of speaking and energy level indicates mania or depression. Work history can be helpful in determining information related to a client's ability to fit in socially but is not included in observational data.
What mood disorder has alternating sad and elated mood, resembling bipolar disorder, but less extreme mood shifts?
- A. Euthymia
- B. Dysthymia
- C. Cyclothymia
- D. Psychotic depression
Correct Answer: C
Rationale: Cyclothymia, alternating sad and elated moods, resembling bipolar disorder, but the extremes of mood are less pronounced. People with normal moods are referred to as euthymic. Dysthymia is a feeling of unremitting sadness and is similar to but less severe than major depression. Psychotic depression encompasses an extreme form of depressive disorder and some persons experience hallucinations and delusions.
A client with major depression is experiencing a disturbed sleep pattern. What nursing intervention will help the client to get maximum sleep during the night?
- A. Acknowledge the client's feeling of despair.
- B. Encourage active exercise before bedtime.
- C. Encourage the client to go to bed early.
- D. Keep the client busy during the day.
Correct Answer: D
Rationale: The nurse should keep the client busy during the day and discourage the client from going to bed early. Left alone, depressed clients are likely to become more vegetative (i.e., they withdraw by sleeping). The nurse should also encourage active exercise during the day but not before bedtime. Exercise relieves anxiety but it may cause stimulation when performed at night. Recognizing a client's mood demonstrates that the nurse has noticed the person and is perceptive but will not help a client with depression in this situation.
Which nursing consideration is most important when administering medications to a suicidal client?
- A. Do not leave any syringe unattended.
- B. Watch the client place all pills in the mouth.
- C. View the inside of the mouth to make sure that all medications are swallowed.
- D. Remove all medications and medication administration equipment from client area.
Correct Answer: C
Rationale: It is most important for the nurse to view the inside of the mouth when administering medications. This is done by inspecting the client's mouth and under the tongue because clients may 'cheek' medications to stockpile and use the medications. Not leaving syringes unattended, watching the client place the pills in their mouth, and removing all medications and equipment are all appropriate nursing actions, but the most important is not allowing the opportunity for the client to overdose on medications.
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.