Question 1 of 5.

Extract:The following scenario applies to the next 6 items The nurse in the behavioral health clinic is caring for a 26-year-old female client. Item 4 of 6 Nurses' Note 1025: Client presents for initial evaluation, reporting that she “feels all over the place and it is time that she receives some treatment.” “At times I feel empty inside, sometimes feel hyped up, and at times, like now, I feel sad”. On assessment, the client has a constricted affect, and her eyes were cast downward. Client reports that her depression has been present for as long as she can remember, including throughout grade school. Her first clearly recalled depressive episode occurred in the sixth grade, when she felt she was "not living up to my own expectations." These episodes varied in duration—some lasting several months, others only a few hours—but typically persisted for 2 to 4 weeks. Onset could range from a day to a week, while the offset was often abrupt, resolving within a day or less. She reported intermittent difficulty falling asleep. Lately, she has had to use 2-3 tablets of diphenhydramine to help her fall asleep. She denied experiencing racing thoughts but acknowledged being told on numerous occasions that she spoke in ways that felt ‘pressured.' She also endorsed distractibility and noted frequent difficulty completing tasks. During times of good mood or when she felt "aligned with others,” she found herself more productive, particularly in creative endeavors. However, at other times, even simple tasks felt overwhelming. She described experiencing "a flurry of thoughts," particularly while writing or during creative projects. At age 23, she experienced what she referred to as "an explosive outburst of rage," which culminated in her punching a hole in her roommate's car's windshield. She reports this occurred during a two-day ‘episode' of her being irritable. Medical history of tension headaches, mild eczema in winter months, and seasonal allergic rhinitis. The client consumes 1-2 glasses of alcohol a year. She does smoke cigarettes daily and started smoking when she was 20.

The nurse plans care for the client after they are diagnosed with bipolar II disorder. For each potential intervention, click to specify whether the intervention is appropriate or not appropriate for the client. Note: Each row must have 1 response option selected.

Question 2 of 5.

The nurse is planning care with a Mexican American client who is diagnosed with depression. The client believes in 'mal ojo' (the evil eye), and uses treatment by a root healer. The nurse should do which of the following?

Question 3 of 5.

The nurse is reviewing the laboratory report with the client's lithium level taken that morning prior to administering the 5 p.m. dose of lithium. The lithium level is 1.8 mEq/L. The nurse should:

Question 4 of 5.

After a few minutes of conversation, a female client who is depressed wearily asks the nurse, 'Why pick me to talk to? Go talk to someone else.' Which of the following replies by the nurse is best?

Question 5 of 5.

A male client who is very depressed exhibits psychomotor retardation, a flat affect, and apathy. The nurse observes the client to be in need of grooming and hygiene. Which of the following nursing actions is most appropriate?