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During a mental status examination, which of the following components should not be included in the assessment?
- A. Appearance and behavior
- B. Giving advice
- C. Mood and affect
- D. Cognitive function
Correct Answer: B
Rationale: During a mental status examination, components such as appearance and behavior, mood and affect, and cognitive function are assessed. Giving advice is not a component of a mental status examination as it focuses on evaluating the client's mental state rather than providing guidance or recommendations.
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Which of the following is not a common side effect of selective serotonin reuptake inhibitors (SSRIs)?
- A. Nausea
- B. Insomnia
- C. Weight loss
- D. Sexual dysfunction
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When caring for a client with major depressive disorder, what is the most appropriate short-term goal for the client?
- A. The client will report a decrease in depressive symptoms.
- B. The client will establish a sleep routine.
- C. The client will improve social interactions.
- D. The client will set realistic goals for the future.
Correct Answer: A
Rationale: The most appropriate short-term goal for a client with major depressive disorder is for them to report a decrease in depressive symptoms. This goal is specific, measurable, and achievable, focusing on the primary symptoms of the disorder. By monitoring and assessing the client's self-reported improvement in depressive symptoms, the healthcare team can track progress and adjust interventions accordingly.
A client with bipolar disorder is experiencing a manic episode. Which intervention should the nurse implement to ensure the client's safety?
- A. Provide a structured environment with minimal stimuli.
- B. Monitor the client closely for signs of exhaustion.
- C. Encourage the client to rest and sleep as needed.
- D. Encourage the client to engage in regular physical activity.
Correct Answer: A
Rationale: During a manic episode in bipolar disorder, individuals may exhibit increased energy levels, impulsivity, and reduced need for sleep, which can lead to risky behaviors and accidents. Providing a structured environment with minimal stimuli helps to reduce the risk of overstimulation and impulsive actions, thereby promoting the client's safety. This intervention aims to create a calm and controlled setting that can prevent potential harm to the client during this phase of the disorder.
A client with major depressive disorder is receiving cognitive-behavioral therapy (CBT). Which outcome indicates that the therapy is effective?
- A. The client identifies and challenges negative thoughts.
- B. The client reports an increase in suicidal thoughts.
- C. The client experiences an increase in anxiety.
- D. The client shows no change in behavior.
Correct Answer: A
Rationale: In cognitive-behavioral therapy, identifying and challenging negative thoughts is a fundamental aspect of the treatment process. This cognitive restructuring helps individuals with major depressive disorder to develop healthier thinking patterns and cope more effectively with their emotions, which ultimately leads to improvement in their mental health. Therefore, when a client is able to identify and challenge negative thoughts, it indicates that they are actively engaging in the therapeutic process and making progress towards better mental well-being.
When assessing a client with bipolar disorder who is experiencing a depressive episode, which of the following findings should the nurse not expect?
- A. Low energy
- B. Feelings of hopelessness
- C. Insomnia or hypersomnia
- D. Difficulty concentrating
Correct Answer: D
Rationale: In a client experiencing a depressive episode in bipolar disorder, common findings include low energy, feelings of hopelessness, insomnia or hypersomnia, and decreased appetite. Difficulty concentrating is more indicative of attention deficit disorders or cognitive impairment rather than a typical presentation of a depressive episode in bipolar disorder.