Nokea
Which of the following nursing diagnoses is of highest priority when caring for a client who is depressed and considers suicide?
- A. Suicide Attempt Risk
- B. Injury Risk
- C. Sleep Deprivation
- D. Coping Impairment
Correct Answer: A
Rationale: Clients with a nursing diagnosis of Suicide Attempt Risk are at an increased risk for suicide due to their feeling of despair. Providing nursing interventions that recognize the client's mood and maintain safety is essential. The other nursing diagnoses are also important and may also be appropriate but are not of the highest priority.
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The nurse is caring for a client on long-standing lithium therapy for a bipolar disorder. Which component of drug therapy administration would require follow-up?
- A. A lab result showing serum lithium level of 1 mEq
- B. Client states, 'I use salt on my potato salad.'
- C. Client states, 'I take my medication each morning.'
- D. Client states, 'I only take lithium after breastfeeding.'
Correct Answer: D
Rationale: Follow-up would be required if a client reported breastfeeding and taking lithium. Lithium administered to infants through breast milk can cause toxicity; thus, breastfeeding mothers should avoid use. None of the other options require further intervention.
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.
The nurse has been working with a client who has difficulty controlling mood. The client continues to experience anger outbursts, which makes it difficult to maintain employment. When explaining this dysfunction to the client's family members, which area of the brain does the nurse identify as being the site for mood generation?
- A. The central nervous system
- B. The autonomic nervous system
- C. The limbic system
- D. The peripheral nervous system
Correct Answer: C
Rationale: The limbic system is responsible for mood generation, as it regulates emotions and related behaviors. The central nervous system includes the brain and spinal cord but is too broad to specifically address mood. The autonomic nervous system controls involuntary functions like heart rate, not mood. The peripheral nervous system handles sensory and motor functions outside the central nervous system.
Administering an MAOI with food containing tyramine may develop a potentially fatal condition known as which of the following?
- A. Psychosis
- B. Serotonin syndrome
- C. Hypertensive crisis
- D. Hallucinations
Correct Answer: C
Rationale: When a MAOI is combined with foods containing tyramine, another monoamine, clients are likely to develop a potentially fatal hypertensive crisis, with symptoms such as elevated blood pressure and palpitations.
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.