Mental Health Exam 3

The nurse develops a plan of care for a patient with major depressive disorder (MDD). Which nursing outcomes are appropriate for this patient?

-patient will verbalize two recources of emotional support -patient will report decreased crying spells during day shift -patient will remain free from self harm during hospitilization

An older adult patient whose husband recently died has experienced insomnia and significant weight loss for the past six months. Which techniques should the nurse use when communicating with this patient?

-provide spiritual referrals -encourage supportive relationships -Encourage activities that raise self esteem

A client diagnosed with major depressive disorder received six ECT sessions and aggressive doses of antidepressive medication, the client owns a small business and was counseled not to make major decisions for a month. What is the correct rational for this counseling?

temporary impairments and confusion can occur with ECT

Which collaborative team member would be the most appropriate team lead for a depressed patient who has recently left priesthood?

spiritual counselor

When counseling clients diagnosed with major depressive disorder, what therapy would an advanced practice nurse address the client's negative thought process?

cognotive-bahvioral

A nurse taught the client about a tyramine restricted diet. Which menu selection would indicate that the client understood the information?

Mashed potatos, ground beef patty, corn, green beans and apple pie.

A client diagnosed with major depressive disorder does not interact with others except when address, and then only in monosyllabals, the nurse wants to show nonjudgemental support for the client. Which communication technique will be effect?

Make observations

Which statement is true regarding the diathesis-stress model of depression?

People predisposed to depression can develop depression that is triggered by a stressful life event

Difficulty making decisions is a symptom of which depressive disorder?

Persistant depression disorder

Transcranial Magnetic Stimulation (TCM) is scheduled for a client diagnosed with major depressive disorder. Which comment by the client indicates teaching about the procedure was effective?

"I might be a little dizzy or have a mild headache after the procedure."

A client diagnosed with major depressive disorder tells the nurse, "bad things that happen are always my fault." Which response by the nurse will best assist the client to reframe this over generalization?

Lets look at one bad thing that happened to see if another explanation exists.

A client diagnosed with major depressive disorder repeatedly tells the staff. "I have cancer, it's my punishment for being a bad person." Diagnostic tests reveal no cancer. What is the priority nursing diagnosis?

Risk for suicidal

Which documentation for a client diagnosis with a major depressive disorder indicates the treatment plan was effective

Slept 6 hours uninterrupted, sang with the activity and anticipates seeing grandchild

A client being treated with paroxetine 50 mg po daily reports to theclinic nurse, ―I took a few extra tablets earlier today and now I feel bad.‖ Which assessments are most critical? (Select all that apply.)

-Vital signs -Presence of abdominal pain and diarrhea -Hyperactivity or feelings of restlessness

"No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful?

"I'd like to sit with you 10 min now and 10 min after lunch because I value spending time with you." *Building therapeutic communication.

A client diagnosed with major depressive disorder says, "No one cares about me anymore. I'm not worth anything." Today the client is wearing a new shirt, and has neat clean hair. Which remark by the nurse supports building a positive self esteem for this client?

"You're wearing a new shirt" *neutral comments*

The nurse is caring for a withdrawn patient diagnosed with a depressive disorder. Which statements made by the nurse exemplify appropriate nursing interventions for this patient?

"would you like to go for a walk or watch a movie?" "you are very sweet and kind to everyone on the unit" "You are in a tough spot, but your doing the work to pull yourself through"

A nurse caring for a client diagnosed with major depressive disorder reads in theclient's medical record, ―This client shows vegetative signs of depression.‖ Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.)

-Imbalanced nutrition -sexual dysfunction -Self care deficit -Insomnia

The admission note indicates a client diagnosed with major depressive disorder has anergia and anhedonia. For which measures should thenurse plan? (Select all that apply.)

-Instilling a sense of hopefullness -assisting with self-care activities -accomadating psychomotor retardation

A client diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.)

-offer laxatives if needed -monitor and fluid intake -provide a quiet sleep enviornment

A patient reports unpleasant side effects from antidepressant therapy. Which nonpharmacological options might the nurse recommend to the patient for treating depression?

-suggest the patient enroll in art therapy -encourage the pt to undergo acupuncture -refer the pt to a cognitive behavior therapist

A client being treated for depression has taken setraline daily for a year. the client calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now i am having nausea, nevous feelings and I can't sleep, the nurse will advise the client

Take your dose of antidepressant now and come to the clinic to see the health care provider.

Select the best initial outcome for the nursing diagnosis "Situational low self-esteem related to feeling of abandonment" ?

The client will verbalize realistic positive characteristic about self by (date)

A client was diagnosed with seasonal affective disorder. During which month would the client's symptoms be most acute?

January

A client diagnosed with major depressive disorder was treated with medication and cognitive behavior therapy, the client now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

Social skills training

Which type of statements may indicate the presence of depression?

Statements that reflect negative thoughts about self

During the psyhiatric assessment, the nurse observes the client's facial expression is without emotion and the client says "Life feels so hopeless for me. I've been feeling sad for several months." How will the nurse document the clients affect and mood?

Affect flat; mood depressed

Inappropriate guilt is which type of depressive symptoms?

Subjective

What is the focus of priority nursing interventions for the period immediately after ECT Treatment?

Supporting physiological stability

A client diagnosed with major depressive disorder is receiving imipramine 200 mg at bedtime. Which assessment finding would prompt the nurse to collaborate with the healthcare provider regarding potentially hazardous side effects of the drug?

Urinary retention

What is the priority intervention for a client diagnosed with major depressive disorder and feelings of worthlessness?

Careful unobtrusive observation around the clock ***Watch out for suicide attempt

A nurse provided medication education for the client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning?

Confers with a pharmacist when selecting over the counter medicine.

A client diagnosed with major depressive disorder began taking escitalopram 5 days ago. The client says "the medicine isn't working." what is the nurse's best intervention?

Explain the time lag before antidepressants relieve symptoms

A client diagnosed with depressive disorder begins SSRI antidepressant therapy. What information should the nurse provide to the client and family?

Importance of reporting increased suicidal thoughts.

A client says to the nurse, "My life does not have any happiness in it anymore, I once enjoyed the holidays, but now they're just like another day." The nurse documents this report using what medical term?

anhedonia

Which medical procedure does the nurse anticipate that the health care provider to order for the patient who experiences catatonia due to depression?

electroconvulsive therapy ECT

A dishevled client in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation and has not showered in several days. What action will the nurse take?

firmly and neutrally assist the client with showering.

A nurse instructs the client taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of

hypertensive crisis

A nurse worked with a client diagnosed with major depressive disorder, severe withdrawal and psychomotor retardation. After 3 weeks, the client did not improve, the nurse is most at risk for what feelings?

ineffectiveness and frustration

A client diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer the client?

milk

A client is experiencing psychomotor agitation associated with major depressive disorder. Which observation presented by the client would the nurse associate with these symptoms?

pacing aimlessly around the room.

During the implementation phase of providing nursing care to a depressed patient, what is the primary goal of the nurse?

provide pt safety

The nurse uses the depressive patient's statement, "I don't want to be around anyone right now. I want to be alone," to help formulate which nursing diagnosis?

risk for lonliness

Which tool is an example of collaborative care of the patient with a depressive disorder?

safety plan

Major depressive disorder resulted the client's employment was terminated, the client now tells the nurse "I am not worth the time you spend with me. I am the most useless person in the world. Which nursing diagnosis applies?

situational low self esteem

A client diagnosed with major depressive disorder began taking tiicyclic antidepressant 1 week ago. Today the client says, "I don't think I can keep taking these pills. They make me so dizzy especially when I stand up. the nurse will implement which intervention?

teach the patient strategies to manage postural hypotension

A patient is prescribed a tricyclic antidepressant (TCA) for feelings of hopelessness due to severe insomnia. What should the nurse teach the patient about this medication

the patient may experience constipation when taking a TCA