Question

A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following?

Answer 1

Correct Answers:

Generalized anxiety disorder

Rationale :

🔷 Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry about a variety of topics or situations, lasting for at least 6 months.

🔷 Clients often report difficulty concentrating, restlessness, muscle tension, and persistent nervousness that interferes with daily life.

🔷 Unlike phobias or panic disorder, the anxiety in GAD is diffuse and not limited to specific events.

🔷 The worry is often disproportionate to the actual source of concern and difficult to manage, even when reassured.

🔷 Recognizing GAD helps guide appropriate psychotherapeutic and pharmacologic treatments like CBT and SSRIs.

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Answer 2

Correct Answers:

Sodium

Rationale :

🔷 Sodium plays a key role in regulating lithium levels in the body; low sodium can cause the kidneys to retain lithium, increasing the risk of toxicity.

🔷 Clients taking lithium must maintain a consistent sodium intake and stay hydrated to prevent fluctuations in serum lithium levels.

🔷 Educating clients about diet and fluid balance is essential to reduce serious adverse effects like tremors or seizures.

🔷 The nurse should also caution the client about diuretics or dehydration, which can also increase lithium levels.

🔷 Regular monitoring of lithium levels and electrolytes is critical during therapy.

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Answer 3

Correct Answers:

Hypomanic episodes alternating with major depressive episodes

Rationale :

🔷 Bipolar II disorder is defined by at least one hypomanic episode and one or more major depressive episodes, without full-blown mania.

🔷 Hypomania is less severe than mania and does not cause psychosis or require hospitalization, but it still includes elevated mood and increased energy.

🔷 The depressive episodes tend to be longer and more debilitating, often the reason clients seek treatment.

🔷 Bipolar II is often misdiagnosed as major depression due to subtle or overlooked hypomanic symptoms.

🔷 Early recognition helps prevent progression and mismanagement of mood swings.

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Answer 4

Correct Answers:

Provide a structured environment with predictable routines, and consistent staff

Rationale :

🔷 Clients with PTSD benefit from stability, routine, and predictability, which reduce hypervigilance and increase a sense of control and safety.

🔷 A structured environment reduces triggers that may exacerbate startle responses or paranoia.

🔷 Consistent staffing builds trust and rapport, which are essential in trauma-informed care.

🔷 Sudden changes or chaos in care can intensify symptoms such as flashbacks or panic.

🔷 This approach also facilitates the use of therapeutic interventions like grounding or coping skills.

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Answer 5

Correct Answers:

A mother with a history of depression and minimal social support

Rationale :

🔷 The greatest risk for postpartum depression is a history of mood disorders, especially depression, combined with lack of support.

🔷 Hormonal shifts, sleep deprivation, and caregiving stress make vulnerable clients more susceptible to mood deterioration.

🔷 Social isolation increases the risk by limiting access to emotional reassurance and practical help.

🔷 Early identification and intervention are crucial to prevent harm to both the mother and infant.

🔷 Nurses should assess for support systems, prior psychiatric history, and coping mechanisms in postpartum evaluations.

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Answer 6

Correct Answers:

Monitor the patient closely for signs of mania.

Rationale :

♦️ Fluoxetine is an SSRI, and when prescribed to a client with bipolar disorder, it can trigger a manic episode, especially without a mood stabilizer.

♦️ SSRIs increase serotonin, which may disrupt the delicate balance in bipolar I disorder, leading to euphoria, insomnia, or risk-taking behaviors.

♦️ The nurse must monitor for signs such as rapid speech, inflated self-esteem, or excessive activity.

♦️ Preventing manic episodes is critical in maintaining mood stability and safety.

♦️ This makes close observation a priority whenever antidepressants are initiated in bipolar clients.

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Answer 7

Correct Answers:

Inspect the cuts for debris.

Rationale :

🟣 First priority in self-harm is to assess for physical injury, infection risk, or foreign material, which can complicate healing.

🟣 Ensuring the wounds are clean and free of debris prevents infection and facilitates further treatment.

🟣 After physical safety is established, the nurse can proceed with documentation and behavioral interventions.

🟣 This action also shows concern and respect for the client’s physical well-being, fostering trust and rapport.

🟣 Wound inspection is part of initial triage and risk assessment for self-injurious behavior.

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Answer 8

Correct Answers:

Threatening behaviors

Rationale :

🔴Clients experiencing severe anxiety may exhibit agitation, restlessness, or threatening conduct due to the fight-or-flight response.

🔴 Severe anxiety can impair cognition, impulse control, and communication, leading to verbal or physical aggression.

🔴 This is a response to overwhelming fear or perceived danger, not necessarily intentional hostility.

🔴 Recognizing behavioral escalation early allows for de-escalation techniques and safety interventions.

🔴 Nurses should prioritize environmental safety and initiate calming measures.

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Answer 9

Correct Answers:

Plan the clients schedule to allow time for rituals.

Rationale :

🎯Clients with OCD use rituals to relieve anxiety caused by obsessive thoughts, and abruptly stopping rituals may cause distress or agitation.

🎯 Initially, the nurse should accommodate rituals within the schedule to preserve the therapeutic alliance and minimize disruption.

🎯 As treatment progresses, the goal is to gradually reduce ritual time using behavioral therapy techniques.

🎯 Allowing structured time for rituals helps maintain unit routine while respecting the client’s current coping strategy.

🎯 This plan supports both behavioral stability and trust in the therapeutic process.

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Answer 10

Correct Answers:

Administer the morning dose of lithium.

Rationale :

⏺️ A serum lithium level of 1.0 mEq/L is within the therapeutic range (0.6 to 1.2 mEq/L) and indicates safe continuation of the medication.

⏺️The medication should be administered as ordered to maintain stable blood levels.

⏺️ Consistency in dosing is essential due to lithium’s narrow therapeutic index.

⏺️ Clients should still be monitored for early signs of toxicity such as tremors or GI upset, especially if dehydrated.

⏺️ Lab monitoring should be conducted regularly, particularly during initial therapy.

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QLexNursing

1 :
A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following?

2 :
A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

3 :
A patient with bipolar II disorder is most likely to experience:

4 :
A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

5 :
Which patient is at the highest risk of developing postpartum depression?

6 :
A patient with a history of bipolar I disorder is prescribed fluoxetine (Prozac) for a depressive episode. What is the nurse's priority action?

7 :
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

8 :
A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

9 :
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

10 :
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following?

2 : A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

3 : A patient with bipolar II disorder is most likely to experience:

4 : A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

5 : Which patient is at the highest risk of developing postpartum depression?

6 : A patient with a history of bipolar I disorder is prescribed fluoxetine (Prozac) for a depressive episode. What is the nurse's priority action?

7 : A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

8 : A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

9 : A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

10 : A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?

1 :
A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances, and is unable to control their sense of worry. The nurse should identity that these manifestations indicate which of the following?

2 :
A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

3 :
A patient with bipolar II disorder is most likely to experience:

4 :
A client with PTSD experiences exaggerated startle response. The client is paranoid and hypervigilant. Which nursing intervention is most appropriate?

5 :
Which patient is at the highest risk of developing postpartum depression?

6 :
A patient with a history of bipolar I disorder is prescribed fluoxetine (Prozac) for a depressive episode. What is the nurse's priority action?

7 :
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

8 :
A nurse at a walk-in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?

9 :
A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

10 :
A nurse in an acute care mental health facility is preparing to administer morning medication for a client who has been taking lithium for 2 weeks and has a current lithium level of 1.0 mEq/L. Which of the following actions should the nurse take?