Mental Health Exam 2 part 2 ch. 10 & 14

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

Instilling a sense of hopefulness. Assisting with self-care activities. Accommodating psychomotor retardation

A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute?

January

A patient diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective?

Make observations

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

Risk for suicide

A patient 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 patient to reframe this overgeneralization?

"Let's look at one bad thing that happened to see if another explanation exists."

A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?

urinary retention

Which comments by a nurse are likely to help a patient cope by addressing the mediators of the stress response? (Select all that apply.)

"A divorce, while stressful, can be the beginning of a new, better phase of life." "You mentioned your spirituality. Are there aspects of your faith that could be helpful to you at this time?" "Journaling often promotes awareness of how experiences have affected people." "There is a support group for newly divorced persons in your neighborhood."

A patient tells the nurse, "I will never be happy until I'm as successful as my older sister." The nurse asks the patient to reassess this statement and reframe it. Which reframed statement by the patient is most likely to promote coping?

"I can find contentment in succeeding at my own job level."

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

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

A patient became severely depressed when the last of the family's six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful?

"I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

A patient tells the nurse, "I know that I should reduce the stress in my life, but I have no idea where to start." What would be the best initial nursing response?

"Let's talk about what is going on in your life and then look at possible options."

The adult child of a patient diagnosed with major depressive disorder asks, "Do you think depression and physical illness are connected? Since my father's death, my mother has had shingles and the flu, but she's usually not one who gets sick." Which answer by the nurse best reflects current knowledge?

"Negative emotions and prolonged stress interfere with the body's ability to protect itself and can increase the likelihood of illness."

A patient says, "One result of my chronic stress is that I feel so tired. I usually sleep from 11:00 PM to 6:30 AM. I started setting my alarm to give me an extra 30 minutes of sleep each morning, but I don't feel any better and I'm rushed for work." Which nursing response would best address the patient's concerns?

"Perhaps going to bed a half-hour earlier would work better than sleeping later."

A patient newly diagnosed as HIV-positive seeks the nurse's advice on how to reduce the risk of infections. The patient says, "I went to church years ago and I was in my best health then. Maybe I should start going to church again." Which response will the nurse offer?

"Studies show that spiritual practices can enhance immune system function and coping abilities."

A patient being treated for depression has taken sertraline daily for a year. The patient calls the clinic nurse and says, "I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can't sleep." The nurse will advise the patient to:

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

A patient reports, "I am overwhelmed by stress." Which question by the nurse would be most important to use in the initial assessment of this patient?

"Tell me about the kinds of things you do to reduce or cope with your stress."

The nurse wishes to use guided imagery to help a patient relax. Which comments would be appropriate to include in the guided imagery script? (Select all that apply.)

"With each breath, you feel calmer, more relaxed, almost as if you are floating ..." "You are alone on a beach, the sun is warm, and you hear only the sound of the surf ..." "You have grown calm, your mind is still, there is nothing to disturb your well-being ..."

A patient experiencing significant stress associated with a disturbing new medical diagnosis asks the nurse, "Do you think saying a prayer would help?" Select the nurse's best answer.

"You may find prayer gives comfort and lowers your stress."

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

"You're wearing a new shirt"

According to the Recent Life Changes Questionnaire, which situation would most necessitate a complete assessment of a person's stress status and coping abilities?

A person returning to college after an employer ceased operations

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

Affect flat; mood depressed

A patient nervously says, "Financial problems are stressing my marriage. I've heard rumors about cutbacks at work; I am afraid I might get laid off." The patient's pulse is 112/minute; respirations are 26/minute; and blood pressure is 166/88. Which nursing intervention will the nurse implement?

Direct the patient in slow and deep breathing using abdominal muscles.

When a nurse asks a newly admitted patient to describe social supports, the patient says, "My parents died last year and I have no family. I am newly divorced, and my former in-laws blame me. I don't have many friends because most people my age just want to go out drinking." Which action will the nurse apply?

Discuss how divorce support groups could increase coping and social support.

A patient diagnosed with emphysema has severe shortness of breath and needs portable oxygen when leaving home. Recently the patient has reduced activity because of fear that breathing difficulty will occur. A nurse suggests using guided imagery. Which image should the patient be encouraged to visualize?

Feeling relaxed and taking regular deep breaths when leaving home

An individual says to the nurse, "I feel so stressed out lately. I think the stress is affecting my body also." Which somatic complaints are most likely to accompany this feeling? (Select all that apply.)

Headache Neck Pain Insomnia Anorexia

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system?

Hypothalamus

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

Imbalanced nutrition: less than body requirements Sexual dysfunction Self-care deficit Insomnia

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve?

Mashed potatoes, ground beef patty, corn, green beans, apple pie

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

Milk

Which changes reflect short-term physiological responses to stress? (Select all that apply.)

Muscular tension, blood pressure, and triglycerides increase. Epinephrine is released, increasing heart and respiratory rates. Corticosteroid release increases stamina and impedes digestion. Cortisol is released, increasing glucogenesis and reducing fluid loss.

A patient 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 food and fluid intake. Provide a quiet sleep environment.

A patient is brought to the Emergency Department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are pulse (P) 72 and respiration (R) 16. After being informed surgery is required for the broken leg, which vital sign readings would be expected?

P 80, R 20

Which documentation for a patient diagnosed with major depressive disorder indicates the treatment plan was effective?

Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

Social skills training

A recent immigrant from Honduras comes to the clinic with a family member who has been a U.S. resident for 10 years. The family member says, "The immigration to America has been very difficult." Considering cultural background, which expression of stress by this patient would the nurse expect?

Somatic complaints

A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system will be stimulated in response to this experience?

Sympathetic nervous system

A patient tells the nurse, "My doctor thinks my problems with stress relate to the negative way I think about things and suggested I learn new ways of thinking." Which response by the nurse would support the recommendation?

Teach the patient to recognize, reconsider, and reframe irrational thoughts.

A patient diagnosed with major depressive disorder received six ECT sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.

Temporary memory impairments and confusion may occur with ECT.

A patient who had been experiencing significant stress learned to use progressive muscle relaxation and deep breathing exercises. When the patient returns to the clinic 2 weeks later, which finding most clearly shows the patient is coping more effectively with stress?

The patient's systolic blood pressure has changed from the 140s to the 120s mm Hg.

A patient being treated with paroxetine 50 mg po daily reports to the clinic 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 or restlessness.

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." The nurse documents this report as an example of

anhedonia

Priority interventions for a patient diagnosed with major depressive disorder and feelings of worthlessness should include

careful unobtrusive observation around the clock.

When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using

cognitive-behavioral therapy

A nurse provided medication education for a patient diagnosed with major depressive disorder who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient

confers with a pharmacist when selecting over-the-counter medications.

A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to

explain the time lag before antidepressants relieve symptoms.

A disheveled patient in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. The nurse will

firmly and neutrally assist the patient with showering.

A nurse leads a psychoeducational group for patients experiencing depression. The nurse plans to implement an exercise regime for each patient. The rationale to use when presenting this plan to the treatment team is that exercise

has an antidepressant effect comparable to selective serotonin reuptake inhibitors.

A nurse instructs a patient 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 patient diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of

ineffectiveness and frustration

A patient is experiencing psychomotor agitation associated with major depressive disorder. Which observation would the nurse associate with this symptom? The patient

paces aimlessly around the room.

Which scenario best demonstrates an example of eustress? An individual

prepares to take a vacation to a tropical island with a group of close friends.

A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about

reporting increased suicidal thoughts.

Major depressive disorder resulted after a patient's employment was terminated. The patient now says to the nurse, "I'm 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

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment?

supporting physiological stability

A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse will

teach the patient strategies to manage postural hypotension.

A patient became depressed after the last of the family's six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will

verbalize realistic positive characteristics about self by (date).