A nurse is discussing the care of a patent with major depressive disorder. Which of the following statements indicates an understanding of the teaching?
A. Care during the continuation phase focuses on treating continued manifestations of MDD
B. Treatment of MDD during the maintenance phase lasts 6 - 12 weeks
C. The patient is at greatest risk for suicide during the first weeks of a MDD episode
D. Medication and psychotherapy are most effective during the acute phase of MDD
C
A nurse is caring a for patient with major depressive disorder. Which of the following is a risk factor for depression? (select all that apply)
A. Male sex
B. History of chronic bronchitis
C. Recent death in the family
D. Family history of depression
E. Personal history of panic disorder
B, C, D, E
A nurse is interviewing a patient who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect?
A. Wide fluctuations in mood
B. Minimum of 5 clinical findings of depression
C. Presence of manifestations for at least 2 years
D. Inflated sense of self-esteem
C
A nurse is admitting a patient with major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse’s priority?
A. Placing the patient on one-to-one observation
B. Assisting the patient in performing ADLs
C. Encouraging the patient to participate in counseling
D. Teaching the patient about medication adverse effects
A
A nurse is assessing a patient 4 hours after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report as indications of serotonin syndrome? (select all that apply)
A. Hypothermia
B. Hallucinations
C. Muscular flaccidity
D. Diaphoresis
E. Agitation
B, D, E
A nurse is discussing relapse prevention with a patient who has bipolar disorder. Which of the following should the nurse include in the teaching? (select all that apply)
A. Use caffeine in moderation to prevent relapse
B. Difficulty sleeping can indicate relapse
C. Begin taking medications as soon as relapse beings
D. Participation in psychotherapy can help prevent relapse
E. Anhedonia is a manifestation of a depressive relapse
B, D, E
A nurse is planning care for a patient with bipolar disorder who is experiencing a manic episode. Which interventions should take place? (select all that apply)
A. Provide flexible patient behavior expectations
B. Offer concise explanations
C. Establish consistent limits
D. Disregard patient concerns
E. Use a firm approach with communication
B, C, E
A nurse is discussing early indications of lithium toxicity for a patient with bipolar disorder. Which of the following manifestations should be included in the teaching? (select all that apply)
A. Constipation
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus
B, D
A nurse is admitting a patient with bipolar disorder who is scheduled to begin lithium therapy. When collecting a medical history, which of the following statements should be reported to the provider?
A. Current medical conditions include diabetes that is controlled by diet
B. Recent medications include a course of prednisone for acute bronchitis
C. Current vaccinations include the flu vaccine last month
D. Current medications include furosemide for CHF
D
A nurse is discussing routine follow-up needs with a patient who has a prescription for valproate. Which of the following is recommended for routine monitoring?
A. AST / ALT / LDH
B. BUN / creatinine
C. WBCs / granulocyte counts
D. Sodium / potassium
A
A nurse is providing preoperative teaching for a patient who was informed of the need for emergency surgery. The patient has a respiratory rate of 30 breaths per minute, and states “this is difficult to comprehend. I feel shaky and nervous.” The nurse should identify that the patient is experiencing which level of anxiety?
A. Mild
B. Moderate
C. Severe
D. Panic
B
A nurse is caring for a patient who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the patient? (Select all that apply)
A. Reassure the patient that everything will be ok
B. Discuss prior use of coping mechanisms with the patient
C. Ignore the patient’s anxiety so that she will not be embarrassed
D. Demonstrate a calm manner while using simple and clear directions
E. Gather information from the patient using closed-ended questions
B, D
A nurse is assessing a patient who has major depressive disorder. The nurse should identify which of the following patient statements as an overt comment about suicide? (select all that apply)
A. My family will be better off if I’m dead
B. The stress in my life is too much to handle
C. I wish my life was over
D. I don’t feel like I can’t ever be happy again
E. If I kill myself, my problems will go away
A, C, E
A nurse is caring for a patient who states “I plan to commit suicide.” Which of the following assessments should be the nurse’s priority?
A. Patient’s educational and economic background
B. Lethality of the method and availability of the means
C. Quality of the patient’s social support
D. Patient’s insight into the reasons for the decision
B
A nurse is caring for a patient who is on suicide precautions. Which of the following interventions should the nurse include in the plan of care?
A. Assign the patient to a private room
B. Document the patient’s behavior every hour
C. Allow the patient to keep perfume in their room
D. Ensure that the patient swallows medication
D
