Question

The client presents to the emergency department with a headache in the back of the head, diaphoresis, and neck stiffness. The clients blood pressure measures 180/124 mm Hg and heart rate is 168 beats/min. The spouse says the client is currently prescribed "something for depression" and denies any history of cardiac disease. The nurse should suspect the use of what medication?

Answer 1

Correct Answers:

A monoamine oxidase inhibitor (MAOI)

Rationale :

🔷 The client's elevated blood pressure (180/124 mm Hg), tachycardia, headache, diaphoresis, and neck stiffness are signs of a hypertensive crisis, a known risk when clients taking MAOIs ingest tyramine-containing foods or interact with contraindicated drugs.

🔷 MAOIs block the breakdown of norepinephrine, leading to excessive catecholamine accumulation when triggered.

🔷 The sudden neurological and cardiovascular symptoms, especially with no cardiac history, strongly indicate this dangerous pharmacologic interaction.

🔷 MAOIs include drugs like phenelzine and tranylcypromine, which require strict dietary precautions.

🔷 Immediate intervention is required to prevent stroke, seizure, or death in such a hypertensive crisis.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Monitor the clients whereabouts at all times.

Rationale :

🔶 A sudden lift in mood after a depressive period can signal that the client has made a plan to commit suicide, giving them a false sense of peace.

🔶 Close observation is critical during this phase to prevent self-harm or suicide attempts.

🔶 The nurse should treat this behavioral shift as a red flag, not a sign of improvement.

🔶 Safety precautions should include removal of harmful objects and continuous monitoring.

🔶 Monitoring supports suicide prevention protocols and demonstrates appropriate risk management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Identity the clients nutritional status.

Rationale :

🟡 The client presents with severe weight loss (40 kg / 88 lb) and distorted body image, indicating anorexia nervosa or severe malnutrition.

🟡 Determining the nutritional status is the priority, as this client is at risk for electrolyte imbalances, cardiac arrhythmias, and organ failure.

🟡 A comprehensive assessment should include labs (albumin, electrolytes), BMI, and intake patterns.

🟡 Interventions can only be planned appropriately after identifying immediate physiological needs.

🟡 Medical stabilization always comes before psychological therapy in eating disorder treatment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Rule-conscious behavior.
Difficulty relaxing.
Perfectionist behavior.

Rationale :

Rule-conscious behavior

🔹 Clients with obsessive-compulsive disorder (OCD) often adhere strictly to rules and routines as a way to reduce anxiety.

🔹 This behavior is driven by obsessive fears that something bad will happen if rules are not followed exactly.

🔹 The client may feel compelled to act in a specific order or repeat behaviors a certain number of times to feel safe.

🔹 These behaviors are not simply habits; they are ritualistic responses to intrusive, unwanted thoughts (obsessions).

Difficulty relaxing

🔹 Due to constant internal anxiety and the need to perform compulsions to relieve that anxiety, clients with OCD often struggle to relax.

🔹 They may experience a sense of dread or restlessness if prevented from completing rituals.

🔹 Their thoughts are typically intrusive and persistent, making rest and relaxation difficult.

🔹 This ongoing mental tension results in chronic psychological distress.

Perfectionist behavior

🔹 Clients with OCD tend to exhibit perfectionism, which is the desire for exactness and flawlessness in performance or behavior.

🔹 This stems from the fear that making a mistake or doing something imperfectly will result in harm or negative consequences.

🔹 They often spend excessive time checking, organizing, or redoing tasks to meet unrealistic standards.

🔹 This perfectionism contributes to functional impairment in daily life and work or school performance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

A child whose parents answer questions for the child

Rationale :

🟠 When parents speak for a child, it may indicate controlling behavior, fear, or an attempt to hide abuse.

🟠 In abuse cases, children are often not allowed to speak freely and may look to the parent for permission.

🟠 This behavior warrants further investigation into family dynamics and possible maltreatment.

🟠 The nurse should observe interactions and interview the child privately, if appropriate.

🟠 Emotional abuse or neglect can often manifest in this subtle form of overcontrol.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

The child tells sexually explicit stories to peers.

Rationale :

🟣 Sexualized language, stories, or behaviors that are developmentally inappropriate are strong indicators of sexual abuse.

🟣 Children often re-enact or verbalize what they have experienced, even if indirectly.

🟣 This behavior usually exceeds normal curiosity and reflects exposure to or involvement in sexual acts.

🟣 It is a critical red flag requiring immediate attention, reporting, and psychological support.

🟣 The nurse should follow mandatory reporting protocols for suspected abuse.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Tardive dyskinesia

Rationale :

⚫ Tardive dyskinesia (TD) is a late-onset extrapyramidal side effect of long-term antipsychotic use like chlorpromazine.

⚫ It presents with involuntary movements of the tongue, face, lips, or extremities, which may become permanent.

⚫ Early identification is crucial, as symptoms may worsen with continued medication use.

⚫ TD results from dopamine receptor hypersensitivity due to chronic blockade.

⚫ The nurse should report symptoms to the provider to consider medication adjustment or discontinuation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Identify precipitating factors for ritualistic behaviors.

Rationale :

🟤 Understanding what triggers compulsive behavior helps the nurse and client develop a management plan.

🟤 OCD rituals are usually performed in response to anxiety or intrusive thoughts (obsessions).

🟤 Identifying triggers allows for targeted intervention, such as exposure and response prevention therapy.

🟤 This step should be completed before implementing alternative strategies or relaxation methods.

🟤 Accurate assessment leads to a more effective, individualized care plan.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Offer finger foods to the client frequently.
Weigh client every 3 to 4 days.
Monitor patient safety throughout the day.
Maintain an environment with low stimuli.

Rationale :

Offer finger foods to the client frequently

🔶 Clients in a manic state often experience hyperactivity, poor concentration, and decreased appetite, making sit-down meals difficult.

🔶 Nutrient-dense finger foods allow the client to eat while moving and help prevent weight loss and malnutrition.

🔶 Frequent, small portions ensure the client receives adequate calories, hydration, and essential nutrients throughout the day.

🔶 This strategy is part of supportive nutritional care in managing acute mania.

Weigh client every 3 to 4 days

🔶 Due to high energy expenditure and poor nutritional intake, clients experiencing mania are at risk for rapid weight loss.

🔶 Regular weight monitoring helps the nurse identify trends and intervene early to prevent complications like dehydration or cachexia.

🔶 It also supports the evaluation of nutritional interventions and helps assess treatment effectiveness.

Monitor patient safety throughout the day

🔶 Clients with mania are prone to impulsive, reckless behaviors, which can result in accidental injuries or altercations.

🔶 Continuous safety monitoring helps reduce risk of falls, aggression, self-harm, or harm to others.

🔶 This includes maintaining supervision in high-risk areas (e.g., stairwells, bathrooms) and assessing for suicidal or delusional thoughts.

🔶 Safety is always a priority in managing manic episodes.

Maintain an environment with low stimuli

🔶 A calm, structured setting helps decrease sensory overload, which can intensify manic symptoms.

🔶 Limiting noise, light, and interruptions can reduce excitability, restlessness, and agitation.

🔶 A low-stimulation environment supports emotional regulation and promotes therapeutic interaction.

🔶 It is a core strategy for managing clients in acute psychiatric episodes, particularly mania.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Frequent headaches and digestive disturbances
Low self-esteem
Insomnia
Irritability

Rationale :

Frequent headaches and digestive disturbances

🔷 Adolescents with depression often present with somatic complaints rather than openly expressing sadness or hopelessness.

🔷 Headaches, stomachaches, nausea, and other vague physical symptoms are commonly reported in pediatric and adolescent populations.

🔷 These symptoms are not due to an organic cause but reflect underlying emotional distress.

🔷 Nurses should explore these complaints further to assess for hidden mood disorders.

Low self-esteem

🔷 Negative self-perception is a hallmark of depression in adolescents and can manifest as feelings of worthlessness or guilt.

🔷 It contributes to social withdrawal, poor academic performance, and reluctance to engage in activities.

🔷 This belief system reinforces depressive thoughts and may contribute to suicidal ideation if unaddressed.

🔷 Identifying and addressing self-esteem issues is critical for effective therapeutic interventions.

Insomnia

🔷 Sleep disturbances, including difficulty falling or staying asleep, are very common in adolescent depression.

🔷 Insomnia results from ruminative thoughts, anxiety, and emotional dysregulation, which interfere with rest.

🔷 Sleep deprivation can exacerbate mood symptoms, creating a negative feedback loop.

🔷 Evaluation of sleep patterns should be part of any comprehensive mental health assessment in youth.

Irritability

🔷 Unlike adults, adolescents with depression often display irritability rather than overt sadness.

🔷 This may appear as frequent mood swings, sensitivity to criticism, or angry outbursts.

🔷 It reflects internal emotional turmoil and can affect relationships with family, peers, and teachers.

🔷 Recognizing irritability as a depressive symptom helps prevent misdiagnosis as behavioral issues alone.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

3 :
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

4 :
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

5 :
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

6 :
Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year- old child?

7 :
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

8 :
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

9 :
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

10 :
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)

QLexNursing

3 : A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

4 : A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

5 : A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

6 : Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year- old child?

7 : A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

8 : A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

9 : A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

10 : A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)

3 :
A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

4 :
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

5 :
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

6 :
Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year- old child?

7 :
A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

8 :
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

9 :
A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

10 :
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)