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1. Chapter 17 Which best explains the neurochemical processes responsible for depression? 1. A) Increased activity of dopamine 2. B) Decreased glucocorticoid activity 3. C) Decreased serotonin and norepinephrine activity 4. D) Potentiating of the kindling process Ans: C Feedback: Deficits of serotonin, its precursor tryptophan, or a metabolite (5- hydroxyindole acetic acid, or 5-HIAA) of serotonin found in the blood or cerebrospinal fluid occur in people with depression. Norepinephrine levels may be deficient in depression and increased in mania. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression. Kindling is the process by which seizure activity in a specific area of the brain is initially stimulated. 2. Which is a freudian explanation of the etiology of depression? 1. A) Depression is a reaction to a distressing life experience. 2. B) Depression results from being raised by rejecting or unloving parents. 3. C) Depression results from cognitive distortions. 4. D) Depression is anger turned inward. Ans: D Feedback: Freud looked at the self-depreciation of people with depression and attributed that self- reproach to anger turned inward related to either a real or perceived loss. Meyer viewed depression as a reaction to a distressing life experience such as an event with psychic causality. Horney believed that children raised by rejecting or unloving parents were prone to feelings of insecurity and loneliness. Beck saw depression as resulting from specific cognitive distortions in susceptible people. 3. Which statements about the etiology of bipolar disorder do most psychoanalytical theories subscribe to? Select all that apply. 1. A) Norepinephrine levels may be increased in mania. 2. B) Manic episodes are a ìdefenseî against underlying depression. 3. C) Acetylcholine seems to be implicated in mania. 4. D) The id takes over the ego and acts as an undisciplined hedonistic being (child).

Ans: B, D Feedback: Most psychoanalytic theories of mania view manic episodes as a ìdefenseî against underlying depression, with the id taking over the ego and acting as an undisciplined hedonistic being (child). Norepinephrine levels may be increased in mania, and acetylcholine seems to be implicated in mania, but these are neurochemical theories. Page 1 4. Which variables represent the highest risk for developing major depressive disorder? Select all that apply. 1. A) Male gender 2. B) Mood disorder in first-degree relatives 3. C) Substance abuse 4. D) Divorced 5. E) Older adult Ans: B, D Feedback: Major depression is twice as common in women and has a 1.5 to 3 times greater incidence in first-degree relatives than in the general population. Incidence of depression decreases with age in women and increases with age in men. Single and divorced people have the highest incidence. Depression in prepubertal boys and girls occurs at an equal rate. 5. A concerned family member tells the nurse, ìI am concerned about my brother. He has been acting very different lately.î Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the brother has bipolar disorder? 1. A) Taking unnecessary risks 2. B) Sleeping more 3. C) Intense focus 4. D) Showing low self-esteem Ans: A Feedback: The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter

extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments. Page 2 6. A client is admitted for major depression. What should the nurse expect to find during assessment? 1. A) Anhedonia, feelings of worthlessness, and difficulty focusing 2. B) Depressed mood, guilt, and pressured speech 3. C) Changes in sleep pattern, tired, and grandiose mood 4. D) Difficulty focusing, feelings of helplessness, and flight of ideas Ans: A Feedback: Symptoms of major depressive disorder include depressed mood; anhedonism (decreased attention to and enjoyment from previously pleasurable activities); unintentional weight change of 5% or more in a month; change in sleep pattern; agitation or psychomotor retardation; tiredness; worthlessness or guilt inappropriate to the situation (possibly delusional); difficulty thinking, focusing, or making decisions; or hopelessness, helplessness, and/or suicidal ideation. Grandiose mood, pressured speech, and flight of ideas are associated with mania. 7. A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm? 1. A) Immediately after a family visit 2. B) On the anniversary of significant life events in the client's life 3. C) During the first few days after admission 4. D) Approximately 2 weeks after starting antidepressant medication Ans: D Feedback: Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide. Page 3

8. The nurse is planning care for a client with major depression. Which is an appropriate expected outcome? 1. A) The client will avoid causing harm to others. 2. B) The client will be free from stress. 3. C) The client will independently carry out activities of daily living. 4. D) The client will not experience agitation. Ans: C Feedback: Expected outcomes for the depressed client include the following: ï The client will not injure himself or herself. ï The client will independently carry out activities of daily living (showering, changing clothing, grooming). ï The client will establish a balance of rest, sleep, and activity. ï The client will establish a balance of adequate nutrition, hydration, and elimination. ï The client will evaluate self-attributes realistically. ï The client will socialize with staff, peers, and family/friends. ï The client will return to occupation or school activities. ï The client will comply with the antidepressant regimen. ï The client will verbalize symptoms of a recurrence. Avoiding agitation and harm to others are outcomes more appropriate for a client with mania. It is unrealistic to be completely free from stress. 9. A client who is depressed begins to cry and states, ìI'm just really sick of feeling this way. Nothing ever seems to go right in my life.î Which would be the most appropriate response by the nurse? 1. A) ìDon't cry. Try to look at the positive side of things.î 2. B) ìYou are feeling really sad right now. It's a hard time.î 3. C) ìHang in there. Your medication will start helping in a few days.î 4. D) ìNothing ever goes right?î Ans: B Feedback: Do not cut off interactions with cheerful remarks or platitudes. Do not belittle the client's feelings. Accept the client's verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger). Allow (and encourage) the client to cry. It is important that the nurse does not attempt to ìfixî the client's difficulties Page 4 10. A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

1. A) Administering a sedative that has been prescribed to be used PRN. 2. B) Insisting the client take a ìtime-outî in his room 3. C) Clearing the area of all other clients 4. D) Setting limits on aggressive and intimidating behavior Ans: D Feedback: Because of the safety risks that clients in the manic phase take, safety plays a primary role in care, followed by issues related to self-esteem and socialization. It is necessary to set limits when they cannot set limits on themselves. Giving the client the opportunity to exercise self-control is most therapeutic. If the client cannot control his or her behavior, then more restrictive measures can be taken, such as room restriction or sedation. Clearing the area is not necessary during limit setting and may cause excessive panic on the part of other clients. When setting limits, it is important to clearly identify the unacceptable behavior and the expected, appropriate behavior. All staff must consistently set and enforce limits for those limits to be effective. 11. Which meal would the nurse provide to best meet the nutritional needs of a client who is manic? 1. A) Peanut butter sandwich, chips, cola 2. B) Fried chicken, mashed potatoes, milk 3. C) Ham sandwich, cheese slices, milk 4. D) Spaghetti, garlic bread, salad, tea Ans: C Feedback: Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. 12. A client who is manic states, ìWhat time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?î Which would be the most appropriate response by the nurse? 1. A) ìPlease slow down. I'm not sure what you need first.î 2. B) ìYou will have to be quiet and have breakfast after the doctor comes.î 3. C) ìAre you hungry?î 4. D) ìYour thoughts seem to be racing this morning.î Ans: A Feedback:

The speech of manic clients may be pressured: rapid, circumstantial, rhyming, noisy, or intrusive with flights of ideas. The nurse must keep channels of communication open with clients, regardless of speech patterns. The nurse can say, ìPlease speak more slowly. I'm having trouble following you.î This puts the responsibility for the communication difficulty on the nurse rather than on the client. Page 5 13. A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time? 1. A) Accompany the client to his or her room to get dressed. 2. B) Put the client in seclusion for his or her own protection. 3. C) Tell other clients to ignore the behavior because it is harmless. 4. D) Tell the client that the behaviors have to stop right now. Ans: A Feedback: Redirecting the client to appropriate behavior without confrontation is most effective. Seclusion is not an appropriate intervention for this situation. Ignoring the behavior is not indicated. The client is in the manic phase; telling him or her to stop the behavior may make the behaviors escalate. 14. The client with mania attempts to hit the nurse. Which is the best response by the nurse? 1. A) ìDo not swing at me again. If you cannot control yourself, we will help you.î 2. B) ìIf you do that one more time, you will be put in seclusion immediately.î 3. C) ìStop that. I didn't do anything to provoke an attack.î 4. D) ìWhy do you continue that kind of behavior? You know I won't let you do it.î Ans: A Feedback: This response firmly states behavioral expectations and lets the client know his behavior will be safely controlled if he is unable to do so. The other choices are not appropriate responses to this situation. 15. During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this

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