Option A: Reduced levels of anxiety do not indicate an

Answers and Rationale

improvement in depressive symptoms.

Option C: Compliance with medications does not indicate

improvement in depression.
1. Answer D. Delusions of grandeur
Option D: Requests to talk to the nurse vary. Requests may

show trust in the nurse but are not a sign that depression has
Delusions of grandeur are symptomatic of manic clients, not clients
diminished.
withdrawing from alcohol. The symptoms and history of alcohol abuse

suggest this client is in alcohol withdrawal.

4. Answer C. Changes in the sensory environment.

Option A: Diaphoresis and tremors occur in the first phase of

Because the confusion occurs at sundown, the cause probably
alcohol withdrawal.
changes in the sensory environment. Sundown syndrome is related to
Option B: The blood pressure and heart rate increase in the
environmental and sensory abnormalities that lead to acute confusion.
first phase of alcohol withdrawal.

Option C: Illusions are common in persons withdrawing from Option A: An underlying depression does not cause
alcohol. Illusions occur most often in dim artificial lighting where the sundown syndrome.
environment is not perceived accurately. Option B: There is not sufficient evidence to suggest he has

inadequate cerebral blood flow.

2. Answer D. Providing for client safety by limiting his privileges.
Option D: Fluctuating levels of oxygen exchange do not

cause sundown syndrome.

Mr. Peterson has been assaultive with the landlord, and it is reasonable

to expect that he may be with peers and staff. His mental illness
5. Answer A. One (1) week.
produces a hyperactive state and poor judgment and impulse control.

External controls such as limiting of unit privileges will assist in feelings Beneficial effects of ECT usually are evident after the first several
of security and safety. treatments. Since treatments are administered at intervals of 48 hours,

these effects are apparent after one week of therapy. Beneficial effects
Option A: Food and fluids are necessary. However, Mr.
of ECT therapy are usually seen before three weeks. It takes three to
Petersons hyperactivity does not allow him to sit quietly to eat. Finger
four weeks for tricyclic antidepressants to take effect. Beneficial effects
foods on the run will provide needed nourishment.
of ECT therapy are usually seen before four weeks. It takes three to
Option B: When hyperactivity decreases, then approach Mr.
four weeks for tricyclic antidepressants to take effect. Beneficial effects
Petersons. regarding hygiene and grooming needs.
of ECT therapy are usually seen after the first few treatments.
Option C: Medications will be ordered. However, a thorough

evaluation must be done first. 6. Answer D. Whether she has a sexual relationship with a

boyfriend.
3. Answer B. Changes in vegetative signs.

It is inappropriate to ask about her sexual relationships.

Vegetative signs such as insomnia, anorexia, psychomotor

retardation, constipation, diminished libido, and poor concentration are Option A: Information about mood changes is important to
biological responses to depression. Improvement in these signs assess, as bulimia is often associated with affective disorders.
indicates a lifting of the depression.
 Option B: Family functioning is the most essential point to Infant baptism is mandatory in the Roman Catholic belief especially if a

assess, as it reveals if binge eating is triggered by conflict within the neonate is not expected to live. Anyone may perform this if an infant or

family. child is gravely ill.

Option C: Information about the ability to socialize with peers

Option A refers to the Christian Science belief.
is important to assess, as it is possible the problem initiated with peer
Option B is a belief of Russian Orthodoxy.
relationships.
Option C: Mormons believe in divine healing with the laying

7. Answer D. Increased interest in sex. on of hands.

Interest in sex is markedly decreased in depression. 11. Answer D. I have tried leaving, but have always gone back.

Option A: Indecisiveness and fear of being wrong are Victims develop a high tolerance for abuse. They blame themselves for

common in depression. being victimized. All members of the family suffer from the effects of

Option B: Depression creates feelings that nothing will ever abuse, even if they are not the actual victims. For these reasons,

improve. victims often have an extensive history of abuse and struggle for a long

Option C: The risk of depression is increased when there is a time before they can leave permanently.

family history.
12. Answer A. You look upset. Would you like to talk about it?

8. Answer A. Demonstrates the relaxation response when asked.

Giving broad opening statements and making observations are

The ability to use relaxation is basic to treatment of phobia. examples of therapeutic communication. The other options are too

specific or focused on being therapeutic.

Option B: Clients with phobias are resistant to insight

therapy. 13. Answer C. Achieve clients therapeutic goals

Option C: Riding the elevator accompanied by the nurse is

Activity groups are used to enhance the therapeutic milieu and to meet
an appropriate long-term goal.

Option D: Role playing may be appropriate after the client the clinical and social needs of clients, e.g., to minimize withdrawal and

has learned relaxation. regression, to develop self-care skills, etc.

14. Answer D. Come play Chinese Checkers with Gerry and me.
9. Answer C. Tell me about your week prior to being admitted.

This gradually engages the client in interactions with others and uses
This is an open-ended question which is non-judgemental and allows
positive behavioral expectation.
for further discussion. The topic is also nonthreatening yet will give the

nurse insight into the clients view of events leading up to admission. It

15. Answer D. Attaching a wander guard sensor band to the
is the only option that is client centered. The other options focus on the
clients wrist
pills.

This type of identification band easily tracks the clients movements

10. Answer D. Pour fluid over the forehead backward towards the
and ensures safety while wandering on the unit.
back of the head and say I baptize you in the name of the father,

the son and the holy spirit. Amen.

16. Answer C. Simply state the food is not poisoned
 This action presents reality. Nonverbal, gentle touch is an important tool here. Providing

appropriate forms of touch to reinforce caring feelings. Because tactile

17. Answer D. Safety
contacts vary considerably among individuals, families, and cultures,

the nurse must be sensitive to the differences in attitudes and practices

Safety is a priority of care for the depressed client. Precautions to
of clients and self.
prevent suicide must be a part of the plan.

20. Answer D. Dispositional crisis

18. Answer B. Control over ones response to stress is possible.

A dispositional crisis is a response to an external situational crisis.

When learning to manage stress, it is helpful to believe that one has
External anger at work is the dispositional crisis displaced to his wife
the ability to control ones response to stress.
through abuse.

Option A: It is impossible to avoid stress, which is a normal

Option A: Psychiatric emergency crisis is when the
experience.
individuals general functioning has been severely impaired, and the
Options C and D: Stress can be positive and growth
individual has been rendered incompetent.
enhancing as well as harmful. The belief that one has some control
Option B: Developmental crisis occurs in response to
can minimize the stress response.
triggering emotions related to unresolved conflict in ones life. This is

called a developmental crisis based on Freudian psychology.

19. Answer C. Gentle touch while guiding ADLs (activities of daily
Option C: An anticipated life transition crisis is a crisis that is
living).
normal in the life cycle; transitional is one over which the person has no

control.