A client with depression has not responded to a tricyclic antidepressant and outpatient electroconvulsive therapy (ECT). The health care provider prescribes selegiline (Eldepryl), and the nurse teaches the client about food to be avoided while taking this medication. Which foods identified by the client allow the nurse to conclude that the instructions have been understood? Select all that apply.
1
Fresh fish
2
Aged cheese
3
Fried chicken
4
Chocolate drinks
5
Leafy vegetables
2 & 4
Foods containing tyramine can cause hypertensive crisis and should be eliminated from the diet. These foods include pickled herring, beer, wine, chicken livers, aged or natural cheese, caffeine, cola, licorice, avocados, bananas, and bologna. Chocolate in moderation is safe for some patients, but it does contain caffeine. Overripe fruits and caffeine have high levels of tyramine, which can cause dangerous hypertension in clients taking monoamine oxidase inhibitors (MAOIs). Also, large amounts of caffeine can increase blood pressure and should be avoided. There is no need to limit the intake of fish, chicken, or leafy vegetables while taking an MAOI.
A nurse is caring for a client who is experiencing a major depression. What feeling should the nurse anticipate that the client will likely have difficulty expressing?
1
Need for comforting
2
Anger toward others
3
Remorse for past behaviors
4
Feelings of low self-esteem
2
The client is dependent, and such individuals can never get enough attention to meet their dependent needs. This unfulfilled need causes anger, which the client has problems expressing for fear of losing the people on whom the client is dependent. The client is expressing the need for comfort. The client is able to express remorse and guilt. The client is able to express feelings of low self-esteem.
A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display?
1
Elated affect related to reaction formation
2
Loose associations related to a thought disorder
3
Physical exhaustion related to decreased physical activity
4
Paucity of verbal expression related to slowed thought processes
4
As depression increases, thought processes become slower and verbal expression decreases due to lack of emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression. Physical exhaustion is associated with bipolar disorder, manic episode; decreased physical activity does not produce physical exhaustion.
A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis?
1
Loss of faith in God
2
Visual hallucinations
3
Decreased social interaction
4
Ambivalent feelings about the future
3
Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Depressed clients are commonly negative and pessimistic, especially regarding their future. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders.
Two weeks after a client has been admitted to the mental health hospital, the client's depression begins to lift. The nurse encourages involvement with unit activities, primarily because this type of activity:
1
Supports self-confidence
2
Provides for group interaction
3
Limits opportunities for suicide
4
Allows verbalization of repressed feelings of hostility
2
Group interaction provides a sense of belonging and fosters the assumption of responsibility. The group is not the best arena for the expression of repressed hostility. Support of self-confidence and limitation of opportunities for suicide are not ensured by group interaction.
When caring for a client with major depression, nurses usually have the most difficulty dealing with the:
1
Client's lack of energy
2
Negative nonverbal responses
3
Client's psychomotor retardation
4
Pervasive quality of the depression
4
Depression is "contagious"; it affects the nurse as well as the client. The client's lack of energy should not make nursing care difficult. These clients usually do not offer negative responses; they offer no response.
A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client?
1
Rigidity and a narrowing of perception
2
Alternating episodes of fatigue and high energy
3
Diminished pleasure in activities and alteration in appetite
4
Excessive socialization and interest in activities of daily living
3
Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.
A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply.
1
Dementia
2
Multiple losses
3
Declines in health
4
A milestone birthday
5
An injury requiring hospitalization
2 & 3
Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.
The nurse notices that one of her clients, who has depression, is sitting by the window crying. The most appropriate response by the nurse is:
1
"It's OK. No need to cry or worry while you're here. We all feel down now and then."
2
"Please don't consider suicide. It really isn't an appropriate way out of your troubles."
3
"You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like."
4
"Why don't you go into the dayroom and join the card game going on? That'll take your mind off of your problems for a while."
3
The nurse is acknowledging that the client is feeling especially down and offering to be available for discussion or just to provide a presence. The response regarding suicide is judgmental and may discourage any effort by the client to initiate a discussion. Telling the client not to cry and suggesting a card game do not acknowledge the client's feelings and appear to trivialize the situation.
When used in combination with certain foods and drugs, monoamine oxidase inhibitors (MAOIs) can cause serious side effects. Which condition could occur in clients treated with MAOIs for depression?
1
A serious drop in blood pressure
2
A serious increase in blood pressure
3
A significant increase in liver enzymes
4
A significant increase in cholesterol levels
2
MAOIs, when taken with foods high in tyramine (e.g., pickled foods, beer, wine, aged cheeses) and drugs such as antidepressants, certain pain medications, and decongestants, can cause a life-threatening increase in blood pressure. For this reason they are seldom used to treat symptoms of depression. MAOIs do not increase liver enzymes or cholesterol levels.
A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time?
1
"I'm going to miss you; we've become good friends."
2
"I know that you're going to be all right when you go home."
3
"Call the contact number we gave you if you have an emergency."
4
"This is my phone number; call and let me know how you're doing."
3
Instructing the client to call the contact number that was provided in case of emergency demonstrates an understanding that the newly discharged client needs to have a support system. Clients need to feel that in a crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead to help the client become a functioning being again. "I know you're going to be all right when you go home" provides false reassurance; the nurse does not know this. "This is my phone number; call and let me know how you're doing" is unprofessional and blurs the roles of nurse and client.
A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I've been sinful and need to be punished." What is the primary focus of nursing interventions?
1
Protecting the client against any suicidal impulses
2
Supporting the client's interest in the outside world
3
Helping the client manage the concern for family members
4
Reassuring the client that past behaviors are not being punished
1
Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client's safety is the focus of nursing interventions. Supporting the client's interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client's belief.
A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity?
1
Find solitary pursuits that the client can enjoy.
2
Speak to the client about the importance of entering into activities.
3
Ask the health care provider to speak to the client about participating.
4
Invite another client to take part in a joint activity with the nurse and the client.
4
Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the health care provider to speak to the client about participating transfers the nurse's responsibility to the health care provider.
A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?
1
It must be given with milk and crackers to avoid hyperacidity and discomfort.
2
Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis.
3
The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks.
4
The blood level should be checked weekly for 3 months to monitor for an appropriate level.
3
Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with the monoamine oxidase inhibitors. Weekly blood level checks are not necessary with fluoxetine.
A depressed client has been prescribed a tricyclic antidepressant. How long should the nurse inform the client that it will take before the client notices a significant change in the depression?
1
4 to 6 days
2
2 to 4 weeks
3
5 to 6 weeks
4
12 to 16 hours
2
It takes 2 to 4 weeks for the tricyclic antidepressant to reach a therapeutic blood level. Four to 6 days and 12 to 16 hours are both too short of time spans for a therapeutic blood level of the drug to be achieved. Improvement in depression should be demonstrated earlier than 5 to 6 weeks.
A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention?
1
Introducing the client to one other client
2
Requiring participation in therapy sessions
3
Encouraging interaction with others in small groups
4
Conveying an attitude of concern that is not intrusive
4
Conveying concern without being intrusive will allow the client to control the pace of development of the nurse-client relationship. Depressed clients are unable to move into relationships with other clients or group situations. It is too early for therapy sessions; the first thing that must be established is a trusting nurse-client relationship.
A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client?
1
Outbursts of anger
2
Focused concentration
3
Preoccupation with delusions
4
Intense interpersonal relationships
1
Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.
A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when he states that one major disadvantage of ECT is that:
1
The seizures may cause bone fractures.
2
Relief of symptoms requires many weeks of treatment.
3
Memory is impaired just before and after the treatment.
4
Loss of mental function occurs and continues for a long time.
3
Impaired memory is an expected side effect of the therapy. Succinylcholine (Anectine) prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.
A client is admitted with the diagnosis of borderline personality disorder/possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client?
1
Degree of anger
2
Potential for suicide
3
Level of intelligence
4
Ability to test reality
2
Depressed clients may use suicide as the ultimate escape from feelings; ensuring safety by protecting the client from self-harm is the priority. Although degree of anger is important, it is not the priority. Assessment of the level of intelligence is unnecessary; clients with a diagnosis of borderline personality disorder are usually of average intelligence. Clients with a diagnosis of borderline personality disorder are more concerned with satisfying their needs than testing reality; they are more concerned about themselves than others or the environment.
When teaching parents about childhood depression the nurse should say that it:
1
May appear as acting-out behavior
2
Does not respond to conventional treatment
3
Looks almost identical to adult depression
4
Is short in duration and has an early resolution
1
Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may indicate an underlying depression. Adult and childhood depression may be manifested in different ways. Childhood depression is not necessarily short and requires treatment. Many conventional therapies for adults with depression, including medication, are effective for children with depression.
A client is admitted to the hospital with a diagnosis of depression. What clinical manifestations of depression does the nurse expect when assessing this client?
1
Flight of ideas
2
Suspicion of others
3
Psychomotor retardation
4
Intrusive social behaviors
3
Both thought and motor activity, which require physical and psychic energy, are commonly slowed when someone is depressed. Flight of ideas is associated with manic behavior because it requires psychic energy. Suspicion is associated with paranoid ideation and is less common with depression. Intrusive social behaviors are associated with manic behavior.
During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply.
1
Lethargy
2
Ambivalence
3
Emotional lability
4
Increased appetite
5
Long periods of sleep
1,2,3
Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is associated with depression.
An effective mood-stabilizing drug used in clients with bipolar disorder in the acute treatment of mania and prevention of recurrent mania and depressive episodes is:
1
Doxepin (Sinequan)
2
Clozapine (Clozaril)
3
Amitriptyline (Elavil)
4
Lithium carbonate (Lithium)
4
Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to calm acute manic symptoms and relieve recurrent mania. Doxepin and amitriptyline are antidepressants used to treat depression but not mania. Clozaril is an antipsychotic medication used to control hallucinations and delusions in patients with psychosis but is not a first-line drug because of its side effects, which include seizures and significant weight gain.
A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Select all that apply.
1
Insomnia
2
Irritability
3
Excessive eating
4
Decreased libido
5
Financial irresponsibility
1,2,5
During a manic episode there is a decreased need for sleep and clients do not feel tired. During a manic episode the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode there is a decrease in appetite. The client's increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode. During a manic episode impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences.
A client has been found to have bipolar disorder and is being prescribed lithium carbonate (Lithium). In light of the information shown, the nurse provides teaching to the client. Select all that apply.
TSH (10)
Sodium (132)
1
Lithium can affect WBC production and therefore increases her risk for infection.
2
Her current thyroid function will require frequent assessments while she takes lithium.
3
Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level.
4
Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy.
5
The current hemoglobin and hematocrit call for regular monitoring is needed once the lithium level is stabilized.
2,3
Lithium carbonate therapy can negatively affect thyroid function; the client's current TSH is at the high normal level and so frequent checks are appropriate. Low serum sodium levels would result in the kidneys' reabsorbing the lithium; this situation would lead to lithium toxicity. The health care provider must first be notified of the lab result. Lithium is not known to have a negative effect on WBC, platelet, or RBC production.
Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply.
1
Passivity
2
Dysphoria
3
Anhedonia
4
Grandiosity
5
Talkativeness
6
Distractibility
4,5,6
Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Dysphoria, a depressed, sad mood, is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.
A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply.
1
Touching the client to provide reassurance
2
Providing a structured environment for the client
3
Ensuring that the client's nutritional needs are met
4
Engaging the client in conversation about current affairs
5
Designing activities that require the client to maintain contact with reality
2,3
Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.
A client is receiving carbamazepine (Tegretol) for the treatment of a manic episode of bipolar disorder. What should the nurse include when planning client teaching about this medication? Select all that apply.
1
"You have to eat a low-sodium diet every day."
2
"You'll have to take a diuretic with this medication."
3
"You'll have to take this medication for the rest of your life."
4
"You may want to suck on hard candy when you get a dry mouth."
5
"We'll need to test your blood often during the first few weeks of therapy."
4,5
Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. Carbamazepine can cause severe bone marrow depression in the early phase of therapy. Also, the drug level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required; nor is a diuretic. The client may or may not have to take the medication for life.
A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment?
1
Doing a needlepoint project
2
Joining a brief swimming competition
3
Walking around the facility with a nurse
4
Playing a board game with another client
3
Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client's anxiety. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.
A 25-year-old woman with the diagnosis of bipolar disorder, manic episode, is admitted to the psychiatric unit. A nurse on the unit reviews the admission information provided by the client's husband and assesses the client. In light of the information in the chart, what is an appropriate nursing intervention?
1
Assigning the client to a private room
2
Suggesting that the client play cards with several other clients
3
Encouraging the development of insight through introspection
4
Having the client sit at the communal dining table during meals
1
During the acute phase of mania, care should be focused on maintaining the safety of the client and others and decreasing the client's energy expenditure. Hypersexuality is often associated with the manic episode of bipolar disorder. Obtaining sexual pleasure by exposing the genitals (exhibitionism) is a paraphilia. A private room protects the other clients and provides privacy for the client. The client is too hyperactive to engage in group activities, and hypersexual behavior may precipitate anxiety in the other clients. Also, manic clients can be overly competitive, which may disturb the other clients. Activities at this time should be solitary or one-on-one with the nurse or nursing assistant. Manic clients have flight of ideas (rapid racing thoughts) and are easily distracted. Introspection and the development of insight cannot occur during this phase of the illness. The hyperactive client will not have the self-control to sit long enough to eat a meal. The nurse should provide finger foods and other portable foods (e.g., sandwich, fruit, milkshake) and encourage the intake of food with short declarative statements that direct the client to eat (e.g., "Finish your sandwich," "Eat this banana").
Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. The most important intervention for the client who is given a PRN medication and confined to involuntary seclusion is to:
1
Continue intensive nursing interactions.
2
Evaluate the client's progress toward self-control.
3
Determine whether any staff member has been injured.
4
Observe the client for side effects of the medication given to the client.
2
For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.
A client with a diagnosis of bipolar I disorder with rapid cycling is readmitted 4 months after discharge. On the first day on the unit the client continually interrupts the nurse and is increasingly talkative and loud. What is the most therapeutic response by the nurse?
1
"You seem to have a need to interrupt me."
2
"How's your relationship with your spouse?"
3
"Do you realize that you're talking loud and fast?"
4
"Tell me about the medication you've been taking."
4
Antidepressants can induce rapidly cycling behavior, or the client may not be taking medications as prescribed; asking the client to talk about the medication will elicit information in a nonchallenging, nonthreatening manner. Observing that the client seems to have a need to interrupt the nurse is challenging and is not focused on assessing the problem. The question "How is your relationship with your spouse?" is not focused on the behavior being manifested. Asking the client whether he realizes that he is speaking loudly and quickly does little to promote discussion.
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