A. Asking the client to independently create her own schedule may be overwhelming for someone with major depressive disorder, especially during the acute phase, due to impaired concentration and low motivation.

B. Teaching passive communication is not appropriate; assertive communication is more therapeutic and promotes healthy interpersonal interactions.

C. Limiting involvement in unit activities can increase isolation and worsen depressive symptoms. Structured, supportive activities are encouraged.

D. Clients with major depressive disorder often experience poor self-care. The nurse should assess and assist with grooming to promote dignity and gradually encourage independence.

A. This directive is overly confrontational and lacks redirection; clients with mania may respond better to calm, supportive redirection rather than commands.

B. Giving the client control over all activity choices can be overwhelming and may worsen manic behavior. Structured guidance is more appropriate.

C. This statement is judgmental and may be perceived as critical or shaming, which can escalate agitation or reduce cooperation.

D. Offering a high-calorie, easy-to-consume item like a milkshake helps address nutritional needs without requiring the client to sit and eat a full meal. It also provides gentle redirection in a non-confrontational way, which is effective during acute mania.

A. Wanting to be with peers more than parents is developmentally appropriate for adolescents and does not necessarily indicate suicidal intent.

B. Preferring to eat meals while watching TV may reflect personal habits or a desire for distraction but is not a direct indicator of suicidal ideation.

C. Avoiding discussion of the suicide attempt may reflect discomfort or embarrassment, which is not uncommon post-crisis, but it doesn't alone suggest ongoing suicidal intent.

D. Giving away valued possessions, such as a CD collection, is a red flag behavior often associated with suicidal intent, as it may indicate the person is preparing for death and saying goodbye.

A. Drinking a glass of milk with each dose can help buffer the stomach lining and reduce gastrointestinal upset, which is a common side effect of chlorpromazine.

B. Lying down after taking the medication is not recommended, as it may increase the risk of esophageal irritation or reflux.

C. Taking chlorpromazine on an empty stomach can actually increase gastrointestinal irritation and worsen upset stomach.

D. While adjusting the dose is a provider’s responsibility, the nurse should first offer practical interventions to manage side effects before suggesting changes to the prescribed dosage.

A. Drinking 2 liters of fluids daily is appropriate and helps maintain adequate hydration, which is important in preventing lithium toxicity.

B. Foods high in tyramine interact with MAOIs, not lithium; this is not a relevant concern for lithium therapy.

C. Consuming 2 to 3 grams of sodium daily is within the normal dietary range and supports stable lithium levels, as lithium and sodium compete for reabsorption in the kidneys.

D. Running 4 miles outdoors daily can lead to excessive sweating and dehydration, which can concentrate lithium levels in the blood and increase the risk of toxicity. Adequate hydration and monitoring sodium loss are critical during heavy physical activity.

A. Discolored urine is not a known or serious adverse effect of buspirone and typically does not warrant reporting.

B. Decreased appetite can occur but is usually mild and not typically a reason to stop the medication.

C. Hallucinations are not a common side effect of buspirone and may indicate a serious reaction or an underlying worsening of the mental health condition. This should be reported to the provider immediately.

D. Sweating can occur with buspirone but is generally considered a mild and non-serious side effect.

A. Atropine is an anticholinergic commonly administered before ECT to decrease secretions and reduce the risk of bradycardia during the procedure.

B. Diphenhydramine is an antihistamine used for allergies or mild sedation but is not indicated in the ECT pre-procedure protocol.

C. Fluoxetine is an SSRI used for depression but should typically be held or managed carefully in clients receiving ECT, as some antidepressants can interfere with seizure threshold.

D. Epinephrine is used in emergency situations such as anaphylaxis or cardiac arrest and is not part of the routine pre-ECT medication regimen.

A. Encouraging the client to identify positive qualities is helpful for self-esteem and cognitive restructuring, but it is not a direct relaxation technique.

B. Identifying previous accomplishments may improve self-confidence, but it does not directly address anxiety or promote immediate relaxation.

C. Assisting the client in practicing meditation directly promotes relaxation by helping reduce physiological symptoms of anxiety and fostering a sense of calm and focus.

D. Recognizing spiritual preferences is important for holistic care, but it is not a specific intervention aimed at promoting relaxation.

A. Wernicke-Korsakoff syndrome is most commonly associated with chronic alcohol use disorder, leading to thiamine deficiency, which results in the neurological symptoms of the syndrome.

B. Opiate addiction is not directly related to Wernicke-Korsakoff syndrome, which is primarily linked to alcohol abuse and thiamine deficiency.

C. While HIV can cause neurological impairments, it is not typically associated with Wernicke-Korsakoff syndrome.

D. Alzheimer's disease has a different pathophysiology and is not directly related to Wernicke-Korsakoff syndrome, though both involve cognitive impairment.

A. Reflection involves paraphrasing the client’s feelings or thoughts, but the nurse's response does not reflect the client’s delusion.

B. While the nurse acknowledges the client’s statement, the response does not demonstrate empathy for the delusion; rather, it maintains focus on the current reality and the need to attend therapy.

C. The nurse clearly articulates what is expected of the client (attending group therapy), which helps set appropriate boundaries and structure for the client.

D. The nurse’s response does not appear to be focused on manipulating or limiting behavior, but rather on reinforcing the expected behavior in a calm, non-confrontational manner.