(N129) EAQ 1

A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I've been sinful and need to be punished." What is the primary focus of nursing interventions? 1. Protecting the client against any suicidal impulses 2. Supporting the client's interest in the outside world 3. Helping the client manage the concern for family members 4. Reassuring the client that past behaviors are not being punished

1 Rationale: Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client's safety is the focus of nursing interventions. Supporting the client's interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client's belief.

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem? 1. Low self-esteem 2. Deficient memory 3. Intolerance of activity 4. Disturbed personal identity

1 Rationale: When a client has an adjustment disorder, anxiety may be related to a disturbance in self-esteem and depression may be related to impaired social interaction. Problems with memory are not specifically related to an adjustment disorder. Activity intolerance, which is related to oxygenation problems, is not associated with adjustment disorders. A client with an adjustment disorder does not experience a disturbance in personal identity.

The nurse is advised to join a community health center that mainly caters to Latino clients. Which skills should the nurse develop to help reduce health disparities? Select all that apply. 1. Learning to speak basic medical Spanish 2. Updating clinical supplies at the health care facility 3. Learning about the health literacy rate of the community 4. Incorporating the health beliefs of the community in any nursing care plans 5. Learning about and respecting unique beliefs and values prevalent among the group

1, 3, 4, 5 Rationale: In order to provide effective health care service to the ethnic group, the nurse should learn to speak basic medical Spanish. This promotes communication and develops trust between the nurse and the clients. Learning about the clients' health literacy can help the nurse identify areas of opportunity for client education and health promotion. Incorporation of beliefs and values in plans of care can make the care more effective. The nurse should learn about the unique values and beliefs of the ethnic group and respect them to deliver equitable health care. Updating the clinical supplies at the health care facility is a basic responsibility of the nurse, but it will not help reduce health disparity.

When caring for a client who has sustained a closed head injury, it is important that the nurse assess for which clinical indicator(s)? Select all that apply. 1. Slowing of the heart rate 2. Diminished carotid pulses 3. Bleeding from the oral cavity 4. Absence of deep tendon reflexes 5. Increased pulse pressure 6. Altered level of consciousness

1, 3, 5, 6 Rationale: Increased intracranial pressure from bleeding into and swelling of tissues within the cranium results in a slowing of the heart rate, an increased pulse pressure (due to increasing systolic blood pressure with a sustained diastolic blood pressure), and an altered level of consciousness. Carotid circulation is not altered. Bleeding from the oral cavity can occur in this situation and should be assessed for the presence of cerebral spinal fluid (CSF). Spinal reflexes generally remain intact.

An adolescent has pinpoint pupils, respiratory depression, and cyanosis. Upon assessment, the school nurse observes needle marks on arms and legs. Which drug is the adolescent probably abusing? 1. Cocaine 2. Narcotics 3. Hallucinogens 4. Central nervous system (CNS) stimulants

2 Rationale: Opioids such as morphine, heroin, codeine, and fentanyl are grouped under narcotic drugs. Physical signs of narcotic abuse include constricted pupils, respiratory depression and cyanosis. Cocaine creates a state of indefinable high or euphoria; withdrawal signs include depression, irritability, seizures, and cardiovascular manifestations. Hallucinogens produce vivid hallucinations and euphoria; they do not produce physical dependence. Clients with acute intoxication of central nervous system (CNS) stimulants may display aggressive behavior along with psychotic episodes of agitation and restlessness.

A client is admitted to a mental health facility for depression. What action should a nurse take to help the client develop a positive self-regard? 1. Set limits on the client's negative behaviors. 2. Involve the client in activities that promote success. 3. Demonstrate approval of the client's efforts at every opportunity. 4. Encourage the client to participate in activities with other clients.

2 Rationale: Self-esteem and feelings of competence are increased when a person experiences success. Although setting limits on the client's negative behaviors is a necessary intervention when a depressed client tries to engage in self-harm, it will not promote feelings of self-esteem. Clients recognize unwarranted praise and often interpret such responses as a form of belittlement or pity. Encouraging the client to participate in activities with other clients may or may not increase self-esteem; also, the client may not have the physical or emotional energy to interact with other clients.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1. Dementia 2. Multiple losses 3. Declines in health 4. A milestone birthday 5. An injury requiring hospitalization

2, 3 Rationale: Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when the client states that what is one major disadvantage of ECT? 1. The seizures may cause bone fractures. 2. Relief of symptoms requires many weeks of treatment. 3. Memory is impaired after the treatment. 4.Loss of mental function occurs and continues for a long time.

3 Rationale: Impaired memory is an expected side effect of the therapy. Succinylcholine prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.

A client is admitted to the psychiatric service with a diagnosis of severe depression. When approached by the nurse, the client says, "You know I'm a sorry, lazy person. I don't deserve a job. I'm just stupid and no good." What does the nurse conclude that the client is experiencing? 1. Nihilistic delusions 2. Delusions of persecution 3. Feelings of self-deprecation 4. Experiences of depersonalization

3 Rationale: The client's statements are self-derogatory and reveal low self-esteem. There is no evidence of feelings about nonexistence. There is no evidence that the client feels controlled or manipulated by others. There is no evidence that the client has a feeling of unreality or of alienation from the self.

The nurse notices that one of her clients, who has depression, is sitting by the window crying. What is the most appropriate response by the nurse? 1. "It's okay. No need to cry or worry while you're here. We all feel down now and then." 2. "Please don't consider suicide. It really isn't an appropriate way out of your troubles." 3. "You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like." 4. "Why don't you go into the dayroom and join the card game going on? That'll take your mind off of your problems for a while."

3 Rationale: The nurse is acknowledging that the client is feeling especially down and offering to be available for discussion or just to provide a presence. Telling the client not to cry and suggesting a card game do not acknowledge the client's feelings and appear to trivialize the situation. The response regarding suicide is judgmental and may discourage any effort by the client to initiate a discussion.

A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity? 1. Find solitary pursuits that the client can enjoy. 2. Speak to the client about the importance of entering into activities. 3. Ask the primary healthcare provider to speak to the client about participating. 4. Invite another client to take part in a joint activity with the nurse and the client

4 Rationale: Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the primary healthcare provider to speak to the client about participating transfers the nurse's responsibility to the primary healthcare provider.

A client with a diagnosis of major depression refuses to participate in unit activities, claiming to be "just too tired." What is the best nursing approach? 1. Planning one rest period during each activity 2. Explaining why the staff believes that the activities are therapeutic 3. Encouraging the client to express negative feelings about the activities 4. Accepting the client's feelings about activities calmly while setting firm limits

4 Rationale: Fatigue and apathy are symptoms of depression and should be accepted; however, limits should be set to facilitate participation in unit activities. Planning one rest period during each activity allows the client to manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not change the client's mind about them, and this response does not show an understanding of the client's needs. Encouraging the client to express negative feelings about the activities will reinforce negative feelings about participating in them.

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to? 1. Modifying the environment 2. Limiting the client's choices of diet and clothing 3. Encouraging fluid intake 4. Discouraging social interaction to avoid the client's distraction from outside environment

4 Rationale: The nursing student's act of discouraging interactions due to fear of the client's distraction may result in a lack of improvement. Social interactions should be encouraged instead. Modifying the environment may help to provide better healthcare. The nurse should limit the client's choices of food and clothing to relieve any decision-making stress. The nurse should also encourage fluid intake.

Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the primary healthcare provider to speak to the client about participating transfers the nurse's responsibility to the primary healthcare provider. 1. Providing psychotherapy to the client 2. Teaching strategies to overcome depression 3. Encouraging the client to walk for 30 minutes 4. Requesting that the physician change the drug

4 Rationale: Tricyclic antidepressants have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence in older adults. Therefore the priority nursing care for an older client who is prescribed a tricyclic antidepressant is to request that the physician change the drug. Providing psychotherapy is an alternate treatment, which is of medium priority. Teaching strategies to overcome depression is of low priority. Encouraging the client to walk for 30 minutes overcomes the feelings of depression, but it is not the priority.

What is the goal of Healthy People 2020? 1. To ensure the well-being of clients cared for in a hospital setting 2. To encourage the nurse to do good for the client 3. To have the nurse act as an advocate for clients who are not capable of self-determination 4. To eliminate health disparities related to race, ethnicity, and socioeconomic status

4. Rationale: The primary goal of Healthy People 2020 is to eliminate health disparities related to race, ethnicity, and socioeconomic status. This helps to increase the quality of health care and help people live longer. Nonmaleficence is the ethical concept that emphasizes the importance of preventing harm and ensuring the client's well-being. Beneficence is the ethical concept that encourages the nurse to do good for the client. According to the American Nurses Association (ANA) Code of Ethics for Nurses (2010), if the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate within the professional scope of nursing practice.