ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 69 Questions
Question 1 of 5
A client with major depression is experiencing a disturbed sleep pattern. What nursing intervention will help the client to get maximum sleep during the night?
Correct Answer: D
Rationale: The nurse should keep the client busy during the day and discourage the client from going to bed early. Left alone, depressed clients are likely to become more vegetative (i.e., they withdraw by sleeping). The nurse should also encourage active exercise during the day but not before bedtime. Exercise relieves anxiety but it may cause stimulation when performed at night. Recognizing a client's mood demonstrates that the nurse has noticed the person and is perceptive but will not help a client with depression in this situation.
Question 2 of 5
A client with bipolar disorder is having a disturbed thought process. What nursing intervention can help the client to be oriented and accurately perceive circumstances surrounding admission?
Correct Answer: C
Rationale: The nurse should reduce distracting stimuli such as noise and stimulation. External stimuli potentiate client's internal activity. The nurse should not provide ample information at once, but rather should provide information in small amounts, using brief sentences. Brief discussion accommodates short attention span. The nurse should also present reality when the client is delusional and should not support the delusion of the client. Failing to present reality reinforces that the client's delusions are real. Exercise releases energy and reduces the potential for an angry outburst. It will not help a client with disturbed thought processes to be oriented.
Question 3 of 5
The nurse is caring for a female client with mood disorder who is prescribed lithium. What interventions should the nurse perform?
Correct Answer: D
Rationale: Lithium crosses the placental barrier; therefore, its use is contraindicated in pregnant women. The client should use caution when resuming activities such as driving as drowsiness is a common side effect of lithium. The nurse should withhold the administration of lithium if the serum level is greater than 1.5 mEq. Lithium should be administered with meals.
Question 4 of 5
During the assessment of a client with mood disorder, the nurse observes that the client experiences hallucinations and delusions. What form of depressive disorders does the client experience?
Correct Answer: C
Rationale: In psychotic depression, an extreme form of depressive disorder, some persons experience hallucinations and delusions. A reactive or secondary depression is a sad feeling that can be directly attributed to a situation or cause. Mania refers to the frenzied state of euphoria exhibited by persons during the manic phase of bipolar disorder. SAD is a mood disorder characterized by depressive feelings that develop during winter months and then disappear in the spring.
Question 5 of 5
What is an example of sub-acute symptoms that may be observed in the older adult who may be depressed?
Correct Answer: B
Rationale: The examples of sub-acute symptoms that may be observed in the older adult who may be depressed are loss of appetite, trouble sleeping, lack of energy, and weight loss.