Question 1 of 5.

Extract:The following scenario applies to the next 1 items The nurse in the behavioral health unit has completed the morning assessment of a client. Item 1 of 1 Progress Notes Day 1 1100: Client transferred from the emergency department to behavioral health. The client is experiencing an acute manic episode and was found wandering the street with bizarre behavior. The client is alert, oriented to place and time only. Bright and expansive affect. Speech is slightly pressured with a normal pitch. The speech is circumstantial. The client's appearance is disheveled. The thought process is disorganized, and the client denies any hallucinations, although grandiose delusions were noted. Impaired insight and judgment. Psychomotor agitation was present as the client paced in the room during the interview. The plan is to admit involuntarily and start valproic acid to stabilize mood. Day 3 0915: Nursing reports that the client has refused all medications and only eats 5-10% of all meals. The client is alert and oriented to place only. Expansive affect. Speech is pressured with a high pitch. The speech is nonsensical and tangential. The client is dressed in normal hospital attire. The thought process is disorganized, with significant derailments. The client denies any hallucinations, although grandiose delusions were noted—severely impaired insight and judgment. Considerable psychomotor agitation was present as the client paced relentlessly in the room during the interview. Vital Signs Day 1 • Oral Temperature 97.8° F (36.6° C) • Pulse 82 • Respiratory rate 18 • Blood pressure 133/81 mm Hg • Pulse oximetry reading 98% on room air Day 2 • Oral Temperature 98.9° F (37.2° C) • Pulse 94 • Respiratory rate 16 • Blood pressure 127/71 mm Hg • Pulse oximetry reading 97% on room air Day 3 • Oral Temperature 99.5°F (37.5°C) • Pulse 104 • Respiratory rate 18 • Blood pressure 110/74 mm Hg • Pulse oximetry reading 96% on room air Orders Day 3 • discontinue oral valproic acid • valproic acid intravenous piggy-back (IVPB) 15 mg/kg every 12 hours • obtain previous psychiatric medical records from the most recent hospitalization • obtain a complete blood count (CBC) and complete metabolic panel (CMP) • 0.9% sodium chloride (normal saline) 1000 mL, IV, once

The nurse should prioritize......... because of the client's..............

Question 2 of 5.

After a period of unsuccessful treatment with Elavil (amitriptyline), a woman diagnosed with depression is switched to Parnate (tranylcypromine). Which statement by the client indicates the client understands the side effects of Parnate?

Question 3 of 5.

A nurse is conducting a psychoeducational group for family members of clients hospitalized with depression. Which family member's statement indicates a need for additional teaching?

Question 4 of 5.

A client is receiving paroxetine (Paxil) 20 mg every morning. After taking the first three doses, the client tells the nurse that the medication upsets his stomach. Which of the following instructions should the nurse give to the client?

Question 5 of 5.

A client who is depressed states, 'I'm an awful person. Everything about me is bad. I can't do anything right.' Which of the following responses by the nurse is most therapeutic?