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A nurse is assessing a client who has been diagnosed with persistent depressive disorder (dysthymia). Which of the following findings should the nurse expect?
- A. Episodes of hypomania
- B. Periods of elevated mood
- C. Lack of interest in activities
- D. Feelings of detachment from one's body
Correct Answer: C
Rationale: The correct finding the nurse should expect in a client diagnosed with persistent depressive disorder (dysthymia) is a lack of interest in activities. This disorder is characterized by a chronic depressive mood lasting for at least two years, alongside symptoms such as changes in appetite, fatigue, low self-esteem, and difficulty concentrating. Clients with dysthymia do not typically experience hypomania, periods of elevated mood, or feelings of detachment from one's body, which are more commonly associated with other mood disorders. Therefore, options A, B, and D are incorrect findings for a client with persistent depressive disorder.
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A client has been prescribed fluoxetine (Prozac). What information should the nurse include in discharge teaching?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication only when feeling depressed.
- D. Report any unusual side effects to the healthcare provider.
Correct Answer: B
Rationale: The correct answer is to advise the client to avoid drinking alcohol while taking fluoxetine (Prozac) due to potential interactions. Alcohol consumption can increase the risk of certain side effects and may reduce the effectiveness of the medication. Choice A is incorrect because fluoxetine can be taken with or without food. Choice C is incorrect as fluoxetine is usually taken daily regardless of the client's mood. Choice D is not the priority teaching point; while reporting side effects is important, avoiding alcohol is critical due to the potential interactions.
When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?
- A. Restlessness
- B. Rapid heart rate
- C. Sweating
- D. Dry mouth
Correct Answer: B
Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.
A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?
- A. Implement a no-harm contract with the client.
- B. Monitor the client closely for signs of self-harm.
- C. Encourage the client to participate in recreational activities.
- D. Encourage the client to maintain a structured daily routine.
Correct Answer: A
Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.
A client diagnosed with post-traumatic stress disorder (PTSD) is being assessed by a healthcare professional. Which symptom would the healthcare professional expect the client to exhibit?
- A. Delusions of grandeur
- B. Hypervigilance
- C. Obsessive-compulsive behaviors
- D. Periods of excessive sleeping
Correct Answer: B
Rationale: In individuals with post-traumatic stress disorder (PTSD), hypervigilance is a common symptom. Hypervigilance refers to a state of increased alertness, awareness, and sensitivity to potential threats or danger. This heightened state of vigilance can manifest as being easily startled, having difficulty relaxing or sleeping, and constantly scanning the environment for signs of danger. It is an adaptive response to the trauma experienced and can significantly impact the individual's daily functioning. The other options are not typically associated with PTSD. Delusions of grandeur are more commonly seen in certain psychiatric disorders like bipolar disorder or schizophrenia. Obsessive-compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD), not PTSD. Periods of excessive sleeping may be seen in conditions like depression, but they are not a hallmark symptom of PTSD.
A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?
- A. You shouldn't worry about that. It's not real.
- B. I don't see any FBI agents, but it sounds like you're feeling frightened.
- C. Let's talk about something else to take your mind off of it.
- D. Why do you think the FBI is watching you?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.