33 Mood & Affect: Depression

The client states to the nurse, "I take citalopram (Celexa) 40 mg every day like my physician prescribed. I have also been taking St. John's wort 750 mg daily for the past 2 weeks." Which of the following indicate that the client is developing serotonin syndrome? Select all that apply. 1. Confusion. 2. Restlessness. 3. Constipation. 4. Diaphoresis. 5. Ataxia.

1, 2, 4, 5 Serotonin syndrome can occur if a selective serotonin reuptake inhibitor is combined with a monoamine oxidase inhibitor, a tryptophan-serotonin precursor, or St. John's wort. Signs and symptoms of serotonin syndrome include mental status changes, such as confusion, restlessness or agitation, headache, diaphoresis, ataxia, myoclonus, shivering, tremor, diarrhea, nausea, abdominal cramps, and hyperreflexia. Constipation is not associated with serotonin syndrome.

The nurse is conducting an intake interview with an Asian American female who reports sadness, physical and mental fatigue, anxiety, and sleep disturbance. Prior to the client's time with the physician, it is important for the nurse to obtain information about the client's use of which of the following? Select all that apply. 1. Tea. 2. Herbal medicine. 3. Breathing exercise. 4. Massage. 5. Folk healer.

1, 2, 5. It is important for the nurse to obtain information about the client's use of tea, herbal medicine, and a folk healer because the information is critical to the safe prescription of psychotropic medication.

The client diagnosed with severe major depression has been taking Lexapro for the past 2 weeks. Which of the following parameters should the nurse monitor most closely at this time? 1. Suicidal ideation. 2. Sleep. 3. Appetite. 4. Energy level.

1. After about 2 weeks of medication therapy, the nurse should expect improvements in sleep, appetite and energy though mood may not have improved significantly yet. The increased energy related to better sleep and food intake gives the client the ability to act on thoughts to harm self (suicide) since the depressed mood has not completely lifted.

During a group session, a client who is depressed tells the group that he lost his job. Which of the following responses by the nurse is best? 1. "It must have been very upsetting for you." 2. "Would you tell us about your job." 3. "You'll find another job when you're better." 4. "You were probably too depressed to work."

1. By stating, "It must have been very upsetting for you," the nurse conveys empathy to the client by recognizing the underlying meaning of a painful occurrence.

The client is receiving 6 mg of selegiline transdermal system (Emsam) every 24 hours for major depression. The nurse should judge teaching about Emsam to be effective when the client makes which statement? 1. "I need to avoid using the sauna at the gym." 2. "I can cut the patch and use a smaller piece." 3. "I need to wait until the next day to put on a new patch if it falls off." 4. "I might gain at least 10 lb from Emsam."

1. Selegiline transdermal system is the first transdermal monoamine oxidase inhibitor. The client on Emsam needs to avoid exposing the application site to external sources of direct heat, such as saunas, heating lamps, electric blankets, heating pads, heated water beds, and prolonged direct sunlight because heat increases the amount of selegiline that is absorbed, resulting in elevated serum levels of selegiline. Cutting the patch and using a smaller piece will result in a decreased amount of medication absorption, most likely leading to a worsening of the symptoms of depression. The client should apply a new patch as soon as possible if one falls off to ensure an adequate amount of medication absorption. Emsam is not associated with significant weight gain.

When developing the teaching plan for the family of a client with severe depression who is to receive electroconvulsive therapy (ECT), what information should the nurse include? 1. Some temporary confusion and disorientation immediately after a treatment is common. 2. Before an ECT treatment session, the client will be given Ativan to calm their nerves. 3. Clients with severe depression usually do not respond to ECT. 4. The client will not be able to breathe independently during a treatment.

1. The family needs to be informed that some confusion and disorientation will occur as the client emerges from anesthesia immediately after ECT, to lessen their fear and anxiety about the procedure. The nurse will assist the client with reorientation (time, person, and place) and will give clear, simple instructions. The client may need to lie down after ECT because of the effects of the anesthesia. Benzodiazepines (ativan) are discontinued prior to ECT as they will interfere with the treatment. Telling the family that the client will not be able to breathe independently during ECT may frighten them unnecessarily. ECT is used for those who are severely depressed and not responding to pharmacotherapy and for those who are highly suicidal.

The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate? 1. "I'll sit here with you for 15 minutes." 2. "I'll come back a little bit later to talk." 3. "I'll find someone else for you to talk with." 4. "I'll get you something to read."

1. The most appropriate action is for the nurse to remain with the client even if the client does not engage in conversation with the nurse. A client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. However, the nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth.

The client with depression has been consistent with taking 12.5 mg of paroxetine (Paxil) extended release daily. The nurse judges the client to be benefiting from this drug therapy when the client demonstrates which of the following behaviors? Select all that apply. 1. Takes 2-hour evening naps daily. 2. Completes homework assignments. 3. Decreases pacing. 4. Increases somatization. 5. Verbalizes feelings.

2, 3, 5. Paroxetine is a selective serotonin reuptake inhibitor antidepressant that also can be used to treat anxiety. Improved concentration, verbalization of feelings, and decreased agitation or pacing are signs of improvement.

A female client with severe depression and weight loss has not eaten since admission to the hospital 2 days ago. Which of the following approaches should the nurse include when developing this client's plan of care to ensure that she eats? 1. Serving the client her meal trays in her room. 2. Sitting with the client and spoon-feeding if required. 3. Calling the family to bring the client food from home. 4. Explaining the importance of nutrition in recovery.

2. A depressed client commonly is not interested in eating because of the psychopathology of the disorder. Therefore, the nurse must take responsibility to ensure that the client eats, including spoon-feeding the client (placing the food on the spoon, putting the food near the client's mouth, and asking her to eat) if necessary.

A client with major depression and psychotic features is admitted involuntarily to the hospital. He will not eat because his "bowels have turned to jelly," which the client states is punishment for his wickedness. The client requests to leave the hospital. The nurse denies the request because commitment papers have been initiated by the physician. Which of the following should the nurse identify as the criterion for this client's legal commitment? 1. Evidence of psychosis. 2. Being gravely disabled. 3. Risk of harm to self or others. 4. Diagnosis of mental illness

2. Criteria for commitment include being gravely disabled and posing a harm to self or others but this client is not threatening to harm himself in the form of suicide or to harm others. The client is gravely disabled because of his inability to care for himself- namely, not eating because of his delusion.

A client with depression who is taking doxepin (Sinequan) 100 mg P.O. at bedtime has dizziness on arising. Which of the following suggestions is most appropriate? 1. "Try taking a hot shower." 2. "Get up slowly and dangle your feet before standing." 3. "Stay in bed until you are feeling better." 4. "You need to limit the fluids you drink."

2. Doxepin and other tricyclic antidepressants may cause postural hypotension, especially in the morning.

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? 1. "Take the medication an hour before breakfast." 2. "Take the medication with some food." 3. "Take the medication at bedtime." 4. "Take the medication with 4 oz of orange juice."

2. Nausea and gastrointestinal upset is a common, but usually temporary, side effect of paroxetine (Paxil). Therefore, the nurse would instruct the client to take the medication with food to minimize nausea and stomach upset. Other more common side effects are dry mouth, constipation, headache, dizziness, sweating, loss of appetite, ejaculatory problems in men, and decreased orgasms in women.

A client who experienced sleep disturbances, feelings of worthlessness, and an inability to concentrate for the past 3 months was fired from her job a month ago. The client tells the nurse, "My boss was wonderful! He was understanding and a really nice man." The nurse interprets the client's statement as representing the defense mechanism of reaction formation. Which of the following would be the best response by the nurse? 1. "But, I don't understand, wasn't he the one who fired you?" 2. "Tell me more about having to work while not being able to sleep or concentrate." 3. "It must have been hard to leave a boss like that." 4. "It sounds like he would hire you back if you asked.

2. Option 2 focuses on the client and her feelings which is the most effective approach to help her realistically consider her situation and decrease the anxiety that led the client to use the defense mechanism of reaction formation. Option 1 casts doubt on the client's perception, which is likely to increase the client's anxiety and make the client feel defensive. Options 3 & 4 further the client's unrealistic perception of the situation.

When teaching the client with atypical depression about foods to avoid while taking phenelzine (Nardil), which of the following should the nurse include? 1. Roasted chicken. 2. Salami. 3. Fresh fish. 4. Hamburger.

2. Phenelzine is a monoamine oxidase inhibitor (MAOI). MAOIs block the breakdown of amines (norepinephrine, serotonin, dopamine, and tyramine). Foods high in tyramine (fermented, pickled, aged, or smoked) must be avoided because, when they are ingested in combination with MAOIs, a hypertensive crisis occurs.

During an interaction with the nurse, a client states, "My husband has supported me every time I've been hospitalized for depression. He'll leave me this time. I'm an awful wife and mother. I'm no good. Nothing I do is right." Based on this information, which of the following nursing diagnoses should the nurse identify when developing the client's plan of care? 1. Impaired social interaction related to unsatisfactory relationships as evidenced by withdrawal. 2. Chronic low self-esteem related to lack of self-worth as evidenced by negative statements. 3. Risk for self-directed violence related to feelings of guilt as evidenced by statements of suicidal ideation. 4. Ineffective coping related to hospitalizations as evidenced by impaired judgment.

2. The client's negative thinking and statements are directly related to the psychopathology of depression. The client's views and feelings about herself reflect low self-esteem. Although Impaired social interaction, Risk for self-directed violence, and Ineffective coping are possible nursing diagnoses, there are insufficient data to support these diagnoses. Further assessment is needed to identify supportive data.

A client was admitted to the inpatient unit 3 days ago with a flat affect, psychomotor retardation, anorexia, hopelessness, and suicidal ideation. The physician prescribed Effexor XR to be given every morning. The client interacted minimally with the staff and spent most of the day in his room. As the nurse enters the unit at the beginning of the evening shift, the client is smiling and cheerfully greets the nurse. He appears to be relaxed and joins the group for community meeting before supper. How should the nurse interpret this change in behavior? 1. The Effexor is helping the client's symptoms of depression significantly. 2. The client's sudden improvement calls for close observation by the staff. 3. The staff can decrease their observation of the client. 4. The client can now be discharged due to the improvement of his symptoms.

2. The client's sudden improvement and decrease in anxiety most likely indicates that the client is relieved because he has made the decision to kill himself and may now have the energy to complete the suicide. Symptoms of severe depression do not suddenly abate because most antidepressants work slowly and take 2 to 4 weeks to provide a maximum benefit. The client will improve slowly due to the medication.

The client with major depression and suicidal ideation has been taking bupropion (Wellbutrin) for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which of the following behaviors? 1. Seizure activity. 2. Suicide attempt. 3. Visual disturbances. 4. Increased libido.

2. The nurse must monitor the client for a suicide attempt at this time when the client is starting to feel better because the depressed client may now have enough energy to carry out an attempt.

A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse is most therapeutic? 1. Wait for the client to begin the conversation. 2. Initiate contact with the client frequently. 3. Sit outside the client's room. 4. Question the client until he responds.

2. The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client's self-esteem. The nurse's action conveys acceptance of the client as a worthwhile person and provides some structure to the seemingly monotonous day.

The physician orders fluoxetine (Prozac) orally every morning for a 72-year-old client with depression. Which transient adverse effect of this drug requires immediate action by the nurse? 1. Nausea. 2. Dizziness. 3. Sedation. 4. Dry mouth.

2. The presence of dizziness could indicate orthostatic hypotension, which may cause injury to the client from falling.

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? 1. "My husband will slowly feel better as his medicine takes effect over the next 2 to 4 weeks." 2. "My wife will need to take her antidepressant medicine and go to group to stay well." 3. "My son will only need to attend outpatient appointments when he starts to feel depressed again." 4. "My mother might need help with grocery shopping, cooking, and cleaning for a while."

3. Additional teaching is needed for the family member who states her son will only need to attend outpatient appointments when he starts to feel depressed again. Compliance with medication and outpatient follow-up are key in preventing relapse and rehospitalization.

After a period of unsuccessful treatment with Elavil (amitriptyline), a tricyclyic antidepressant, a woman diagnosed with depression is switched to Parnate (tranylcypromine), a MAOI antidepressant. Which statement by the client indicates the client understands the side effects of Parnate? 1. "I need to increase my intake of sodium." 2. "I must refrain from strenuous exercise." 3. "I must refrain from eating aged cheese or yeast products." 4. "I should decrease my intake of foods containing sugar."

3. Cheese and yeast products contain tyramine which the client should avoid to prevent a negative interaction with Parnate, a monoamine oxidase inhibitor.

The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is best to help them prepare for the client's return home? 1. Discourage visitors while the client is at home. 2. Provide for a schedule of activities outside the home. 3. Involve the client in usual at-home activities. 4. Encourage the client to sleep as much as possible.

3. It is best to involve the client in usual at-home activities as much as the client can tolerate them. Discouraging visitors may not be in the client's best interest because visits with supportive significant others will help reinforce supportive relationships, which are important to the client's self-worth and self-esteem. Providing for a schedule of activities outside the home may be overwhelming for the client initially. Involving the client in planning for outside activities would be appropriate. Encouraging the client to sleep as much as possible is nontherapeutic and promotes withdrawal from others.

Which of the following behaviors exhibited by a client with depression should lead the nurse to determine that the client is ready for discharge? 1. Interactions with staff and peers. 2. Sleeping for 4 hours in the afternoon and 4 hours at night. 3. Verbalization of feeling in control of self and situations. 4. Statements of dissatisfaction over not being able to perform at work.

3. The client who verbalizes feeling in control of self and situations no longer feels powerless to affect an outcome but realizes that one's actions can have an impact on self and situations.

A 62-year-old female client with severe depression and psychotic symptoms is scheduled for electroconvulsive therapy (ECT) tomorrow morning. The client's daughter asks the nurse, "How painful will the treatment be for Mom?" The nurse should respond by saying which of the following? 1. "Your mother will be given something for pain before the treatment." 2. "The physician will make sure your mother doesn't suffer needlessly." 3. "Your mother will be asleep during the treatment and will not be in pain." 4. "Your mother will be able talk to us and tell us if she's in pain."

3. The nurse should explain that ECT is a safe treatment and that the client is given an ultra- short-acting anesthetic to induce sleep before ECT and a muscle relaxant to prevent musculoskeletal complications during the convulsion, which typically lasts 30 to 60 seconds to be therapeutic. Atropine is given before ECT to inhibit salivation and respiratory tract secretions and thereby minimize the risk of aspiration. Medication for pain is not necessary and is not given before or during the treatment. Some clients experience a headache after the treatment and may request and be given an analgesic such as acetaminophen (Tylenol).

A client has been taking 30 mg of Cymbalta twice daily for 2 months because of depression and vague aches and pains. While interacting with the nurse, the client discloses a pattern of drinking a 6-pack of beer daily for the past 10 years to help with sleep. What should the nurse do first? 1. Refer the client to the dual diagnosis program at the clinic. 2. Share the information at the next interdisciplinary treatment conference. 3. Report the client's beer consumption to the physician. 4. Teach the client relaxation exercises to perform before bedtime.

3. The nurse should report the client's beer consumption to the physician. Cymbalta should not be administered to a client with renal or hepatic insufficiency because the medication can elevate liver enzymes and, together with substantial alcohol use, can cause liver injury.

Which of the following is the best predictor of a client's favorable response to the choice of an antidepressant? 1. The drug's side effect profile. 2. The client's age at diagnosis. 3. The cost of the medication. 4. A favorable response by a family member.

4. A favorable response by a family member to a medication and a previous response to medication are good predictors of a favorable client response to a medication because the illness is genetic and hereditary.

When assessing a client who is receiving tricyclic antidepressant therapy, which of the following should alert the nurse to the possibility that the client is experiencing anticholinergic effects? 1. Tremors and cardiac arrhythmias. 2. Sedation and delirium. 3. Respiratory depression and convulsions. 4. Urine retention and blurred vision.

4. Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system, include urine retention, blurred vision, dry mouth, and constipation.

Which of the following outcomes should the nurse include in the initial plan of care for a client who is exhibiting psychomotor retardation, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions? 1. The client will initiate interactions with peers. 2. The client will participate in milieu activities. 3. The client will discuss adaptive coping techniques. 4. The client will interact with the nurse.

4. In the initial plan of care, the most appropriate outcome would be that the client will interact with the nurse. First, the client would begin interacting with one individual, the nurse. The nurse would gradually assist the client to engage in interactions with other clients in one-on-one contacts, progressing toward informal group gatherings and eventually taking part in structured group activities.

The nurse is planning care with a Mexican-American client who is diagnosed with depression. The client believes in "mal ojo" (evil eye), and uses treatment by a Curandera (healer). The nurse should do which of the following? 1. Avoid talking to the client about the curandera. 2. Explain to the client that Western medicine has a scientific, not mystical, basis. 3. Explain that such beliefs are superstitious and should be forgotten. 4. Involve the curandera in a consultation with the client, physician and nurse.

4. Including the curandera gives credibility and respect to the client's cultural beliefs. Avoiding conversation about the healer demonstrates either ignorance or disregard for the client's cultural values. Negative comparison of curanderas with Western medicine not only denigrates the client's beliefs, but are likely to alienate him or her and cause them to end treatment.

A client with major depression is to be discharged home tomorrow. When preparing the client's discharge plan, which of the following areas is most important for the nurse to review with the client? 1. Future plans for going back to work. 2. A conflict encountered with another client. 3. Results of psychological testing. 4. Medication management with outpatient follow-up.

4. Medication management with outpatient follow-up is of vital importance to discuss with the client before discharge. The nurse teaches and clarifies any questions related to medication and outpatient treatment. The client also has the opportunity to voice feelings related to medication and treatment. The goal is to assist the client in making a successful transition from hospital to home with optimal functioning outside the hospital for as long as possible.

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? 1. Explaining the importance of hygiene to the client. 2. Asking the client if he is ready to shower. 3. Waiting until the client's family can participate in the client's care. 4. Stating to the client that it's time for him to take a shower.

4. The client with depression is preoccupied, has decreased energy, and cannot make decisions, even simple ones. Therefore, the nurse presents the situation, "It's time for a shower," and assists the client with personal hygiene to preserve his dignity and self-esteem.

A client is taking phenelzine (Nardil) 15 mg P.O. three times a day. The nurse is about to administer the 1 p.m. dose when the client tells the nurse that about having a throbbing headache. Which of the following should the nurse do first? 1. Give the client an analgesic ordered p.r.n. 2. Call the physician to report the symptom. 3. Administer the client's next dose of phenelzine. 4. Obtain the client's vital signs.

4. The nurse should first take the client's vital signs because the client could be experiencing a hypertensive crisis, which requires prompt intervention. Signs and symptoms of a hypertensive crisis include severe headache, a stiff or sore neck, nausea, vomiting, sweating, dilated pupils and photophobia, nosebleed, tachycardia, bradycardia, and chest pain.

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? 1. "I'm assigned to care for you today, if you'll let me." 2. "You have a lot of potential, and I'd like to help you." 3. "I'll talk to someone else later." 4. "I'm interested in you and want to help you."

4. The nurse tells the client that the nurse is interested in her to increase the client's sense of importance, worth, and self-esteem. Also, stating that the nurse wants to help conveys to the client that she is worthwhile and important.