Question

A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

Answer 1

Correct Answers:

"l will use the coping mechanisms that helped me in the past."

Rationale :

🟩 This statement demonstrates insight and adaptive behavior, which is a positive sign in the treatment of major depressive disorder (MDD).

🟩 Relying on previously successful coping mechanisms promotes autonomy, resilience, and emotional regulation.

🟩 It reflects the client’s ability to self-manage symptoms, which supports long-term recovery and relapse prevention.

🟩 Teaching self-care in MDD includes developing personal routines, positive thinking, and engaging in behaviors that have worked historically.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Suppression

Rationale :

🟧 Suppression is a conscious defense mechanism in which an individual voluntarily avoids thinking about distressing thoughts or feelings.

🟧 The client acknowledges the diagnosis but delays dealing with it, choosing to focus instead on an emotionally significant event.

🟧 This is maladaptive when it interferes with necessary planning or treatment, as in the case of a metastatic diagnosis.

🟧 Unlike repression, suppression involves intentional avoidance and is more common in clients experiencing denial or emotional overload.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Reports a lack of sleep

Rationale :

🟩 A decreased need for sleep is a primary symptom of acute mania, where individuals often sleep very little but still feel highly energetic.

🟩 Unlike insomnia, clients with mania do not feel tired or fatigued, even after minimal or no sleep.

🟩 This lack of sleep is caused by excessive dopamine and norepinephrine activity in the brain, which contributes to hyperactivity and racing thoughts.

🟩 It is a reliable behavioral indicator used to differentiate mania from hypomania or depression.

🟩 Monitoring sleep patterns in bipolar disorder is crucial for early intervention, as sleep deprivation can further exacerbate manic symptoms and increase the risk of hospitalization.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

The client's best friend moved away.

Rationale :

🟨 The departure of a best friend represents a significant emotional loss and disruption in the client’s social support system.

🟨 In the recovery period following major surgery like CABG, emotional well-being and social connection play a key role in healing.

🟨 Stress from the loss of a close relationship can impair the immune system, increase cortisol levels, and slow down physical recovery.

🟨 It may also lead to feelings of loneliness, depression, or anxiety, which are detrimental to cardiac rehabilitation efforts.

🟨 The nurse should assess for signs of emotional distress and help connect the client to support groups or counseling to mitigate the impact of this psychosocial stressor.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

"Have you been thinking about harming yourself?"

Rationale :

🟥 This response reflects a direct and therapeutic assessment for suicide risk, which is essential when a client expresses hopelessness.

🟥 Asking about suicidal ideation does not plant the idea in a client’s mind; rather, it opens a safe dialogue and allows for accurate risk assessment.

🟥 It demonstrates professional responsibility and compassion, ensuring that any imminent risks are addressed promptly.

🟥 Suicide risk screening is a standard nursing practice in both inpatient and outpatient mental health settings.

🟥 If the client endorses suicidal thoughts, the nurse can initiate safety precautions, provider notification, and emergency psychiatric intervention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

"l don't feel anything but numbness anymore."

Rationale :

🟫 Emotional numbness or apathy is a concerning indicator of clinical depression, especially when it follows the loss of a loved one.

🟫 While sadness, anger, and yearning are normal in grief, persistent emotional blunting suggests that the grieving process has become pathologic.

🟫 This detachment can interfere with daily functioning, relationships, and the ability to move forward or find meaning after loss.

🟫 The nurse should recognize this as a potential red flag requiring prompt referral to a mental health provider for further evaluation.

🟫 Left untreated, this form of depression can lead to suicidal ideation, social withdrawal, or severe functional decline.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

The client is able to follow commands.

Rationale :

🟪 The ability to follow commands indicates that the client has regained behavioral control and cognitive orientation, which are key criteria for safely removing restraints.

🟪 Restraints are meant to be a short-term safety intervention, only used when a client poses immediate harm to self or others.

🟪 Once the client demonstrates cooperative behavior and responds appropriately to redirection, restraints must be discontinued to prevent unnecessary restriction.

🟪 Continued use of restraints after the client is compliant may violate ethical principles and patient rights.

🟪 The nurse should document the client’s behavioral improvement and perform frequent assessments to determine readiness for restraint removal.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Reports eating twice in the past week

Rationale :

🟥 This is a critical clinical finding, as inadequate nutritional intake places the client at risk for malnutrition, hypoglycemia, and electrolyte imbalances.

🟥 During acute mania, clients often experience reduced appetite, distractibility, and poor insight, leading to skipped meals and dehydration.

🟥 Poor nutritional status not only compromises physical health but can also exacerbate cognitive symptoms and emotional instability.

🟥 Reporting this to the provider is essential to initiate nutritional interventions, possibly including supervised meals or IV fluids.

🟥 Prioritizing physiological stability ensures the client is safe and able to participate in psychiatric treatment effectively.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Put locks at top of doors.
Encourage physical activity prior to bed time.
Position the mattress on the floor.
Install sensor devices on outside doors.

Rationale :

🟩 Put locks at top of doors

🟩 Clients with Alzheimer’s often attempt to wander due to disorientation and confusion, particularly at night.

🟩 Placing locks at the top of doors makes them less visible and accessible, preventing unsupervised exits.

🟩 This promotes home safety while minimizing restraint, which supports client dignity.

🟩 It is a commonly recommended intervention for home dementia care.

Encourage physical activity prior to bedtime

🟩 Structured physical activity can reduce restlessness, improve mood, and promote better sleep quality.

🟩 Many clients with Alzheimer’s experience sundowning and nighttime agitation, which physical exertion may alleviate.

🟩 Daytime activity helps reset the circadian rhythm and decrease nighttime wandering.

🟩 It supports a non-pharmacologic behavioral strategy for managing sleep disruptions.

Position the mattress on the floor

🟩 This intervention reduces the risk of injury in clients who fall out of bed due to nocturnal wandering or agitation.

🟩 It is a low-risk, non-invasive safety method that avoids the use of physical restraints.

🟩 Clients remain more comfortable while being protected from serious injury.

🟩 It is particularly useful for clients with a history of falls, as noted in this scenario.

Install sensor devices on outside doors

🟩 Motion sensors or alarms alert caregivers when the client attempts to exit the home, allowing for prompt redirection.

🟩 These devices serve as a preventative tool against elopement, especially during unobserved hours.

🟩 They help reduce caregiver burden while maintaining client safety.

🟩 This is a vital recommendation for clients with moderate to severe dementia being managed at home.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

"How has this impacted your life?"

Rationale :

🟫 This is a therapeutic, open-ended question that invites the client to explore and verbalize their emotional response to the stroke and disability.

🟫 It helps the nurse assess the client's psychosocial adjustment, coping mechanisms, and any presence of depression or hopelessness.

🟫 Understanding the impact allows the nurse to tailor interventions to the client’s specific emotional and psychological needs.

🟫 It also promotes the nurse-client relationship, as it shows empathy and interest in the client’s lived experience.

🟫 This type of question is essential in developing individualized, patient-centered care plans for clients adjusting to major life changes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

4 :
A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client recovery?

5 :
A nurse is caring for a client who states, 'Things will never work out." Which of the following responses should the nurse make?

6 :
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

7 :
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

8 :
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

10 :
A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

QLexNursing

1 : A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

3 : A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

4 : A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client recovery?

5 : A nurse is caring for a client who states, 'Things will never work out." Which of the following responses should the nurse make?

6 : A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

7 : A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

8 : A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

10 : A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

1 :
A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

3 :
A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

4 :
A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client recovery?

5 :
A nurse is caring for a client who states, 'Things will never work out." Which of the following responses should the nurse make?

6 :
A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

7 :
A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

8 :
A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

10 :
A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?