Psych Exam 3 - Ch. 14 (Depressive Disorders)

Which individual has the highest risk for major depression?

35-year-old woman Females and the 25- to 44-year-old age-group have the highest incidences of depression. p. 246, Box 14.1

Which statement by a patient indicates understanding of the medication teaching provided concerning a prescribed selective serotonin reuptake inhibitor (SSRI)?

"I will immediately report any symptoms of high fever, fast heartbeat, or abdominal pain." High fever, fast heartbeat, or abdominal pain describe symptoms of serotonin syndrome, a life-threatening complication of SSRI medication. The other options are incorrect because the patient should be wearing sunscreen to avoid sunburn, may take over the counter medications if sanctioned by the health care provider, and would not have been educated to report increased thirst and urination as a side effect of SSRI. pp. 258-260

What are the side effects of vagus nerve stimulation (VNS)?

-Cough -Neck pain -Paresthesia Patients who have undergone VNS may have side effects, including paresthesia, neck pain, and cough due to the position and implantation of the VNS device on the vagus nerve. The electrode used for stimulation is placed close to the laryngeal and pharyngeal branch of the left vagus nerve. Stimulation of these nerves causes coughing. The vagus nerve has an inhibitory effect on the heart; therefore bradycardia, not tachycardia, is a symptom associated with vagus nerve stimulation. Vagus nerve stimulation does not alter the neurotransmitter levels in the brain, so the patient does not have delusions. p. 265

A patient with depression was prescribed fluvoxamine. On regular examination, the nurse identifies that the patient is having serotonin syndrome. Which symptoms in the patient support the nurse's assumption? (SATA)

-Hyperactivity -Altered mental states -Abnormally high fever Fluvoxamine is a selective serotonin reuptake inhibitor. It can cause potential side effects such as serotonin syndrome due to overactivation of central serotonin receptors. Serotonin syndrome is characterized by hyperactivity, altered mental state, and hyperpyrexia characterized by excessively high fever. It is also characterized by elevated blood pressure and increased heart rate. p. 260, Box 14.3

Dysthymia cannot be diagnosed unless it has existed for

At least two years Dysthymia is a chronic condition that by definition has to have existed for longer than two years. p. 243

What statement about the comorbidity of depression is accurate?

Depression commonly is seen in individuals with medical disorders. Depression commonly accompanies medical disorders. Depression existing most often as a single entity, seldom seen with substance abuse, and rarely seen with schizophrenia are false statements. p. 246

A depressed patient tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can identify this cognitive distortion as an example of

Learned helplessness Learned helplessness results in depression when the patient feels no control over the outcome of a situation. p. 252

Which food is safe for a patient taking monoamine oxidase inhibitors (MAOIs)?

Pineapple Patients taking MAOIs must avoid foods containing tyramine. Most fruits, like pineapple, are safe to eat while taking MAOIs, as they have low levels of tyramine. Avocados, especially overripe ones, are high in tyramine. Almost all dairy products like cheddar cheese contain tyramine. Chocolate is also a food to avoid. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 262

A patient diagnosed with major depressive disorder has vegetative symptoms. Which nursing diagnosis is most applicable to these symptoms?

Self-care deficit Vegetative signs of depression include grooming and hygiene deficiencies; significantly reduced appetite; and changes in sleeping, eating, elimination, and sexual patterns. Spiritual distress, disturbed thought processes, and risk for self-directed violence relate to assessment findings in depression associated with other symptoms, not vegetative signs of depression. p. 252

When the nurse remarks to a depressed patient, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to

Wait quietly for the patient to reply Depressed patients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply. p. 254, Table 14.3

While several different neurotransmitters are involved in mood stabilization, which are considered the main regulators?

-Norepinephrine -Serotonin Two main neurotransmitters involved in mood are serotonin (5-hydroxytryptamine [5-HT]) and norepinephrine. Research suggests that depression results from the dysregulation of a number of neurotransmitter systems beyond serotonin and norepinephrine. The dopamine, acetylcholine, and glutamate also are believed to be involved in the pathophysiology of a major depressive episode. p. 247

A primary health care provider prescribes electroconvulsive therapy to a patient who is not responding to antidepressant medications. What interventions should the nurse perform before the therapy is administered to the patient?

Administer atropine sulfate before the therapy. Electroconvulsive therapy (ECT) is used for the patients who have major depression and psychotic symptoms, and for patients who don't respond to medication. Atropine sulfate is a short-acting barbiturate and is administered to the patient to induce sleep before initiating ECT. Permission must be taken from the patient's guardians before doing electroconvulsive therapy. Captopril is an angiotensin-converting enzyme inhibitor which is generally prescribed during hypertension. Acetaminophen is a nonsteroidal antiinflammatory drug and is unrelated to electroconvulsive therapy. p. 264

A patient says to the nurse, "I once enjoyed going to parks and museums with my family but that is not fun anymore." How would the nurse document this complaint?

Anhedonia Anhedonia means that there is no pleasure or joy in life. It is a common finding with depression. Anergia refers to a lack of energy or physical passivity. Euthymia refers to a mood state that is normal and moderate, with neither depression nor mania. Self-deprecation refers to negative statements about self. p. 252

A nurse counsels a patient diagnosed with depression to begin a mild exercise regime. What is the physiologic basis of the nurse's recommendation?

Exercise stimulates serotonin production. Exercise stimulates serotonin production, which will help improve the patient's mood. Exercise has biological, social, and psychological effects on symptoms of depression. Inflammation may be a factor in depression, but exercise is not targeted at this aspect of the disorder. While exercise may contribute to improved sleep, it will not necessarily stabilize the sleep pattern. Exercise improves circulation, but does not necessarily eliminate toxins. p. 266

A patient who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The patient mentions that he or she will take the medication along with the St. John's wort he or she uses daily. The nurse should

Explain the high possibility of an adverse reaction Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants. p. 266

A patient was admitted to an intensive care unit after reporting chest pain, an elevated heart rate, and a very high body temperature. The patient's family reported to the nurse that the patient was taking antidepressants. They also reported that the patient started having chest pain after eating avocados and cheese. Which antidepressant medication was the patient likely taking that would have caused this interaction?

Isocarboxazid Some foods, such as cheese, are rich sources of tyramine, which increases the production of serotonin in the body. Patients who are taking isocarboxazid, which is a monoamine oxidase inhibitor (MAOI), should avoid eating foods rich in tyramine because this substance can interact with MAOI drugs and cause adverse effects, such as hypertensive crisis and pyrexia (high body temperature). These reactions are seen within a few hours after consuming the contraindicated foods. The symptoms of hypertensive crisis are chest pain and increased or reduced heart rate. Desipramine is a tricyclic antidepressant and does not cause hypertensive crisis. Trazodone is a serotonin antagonist and reuptake inhibitor (SSRI), and its side effects are sedation and nausea. Hypertensive crisis is not a side effect associated with SSRIs. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI); its side effects are nausea, headache, and dry mouth. p. 260, Table 14.6

A nurse is performing an assessment of a patient with depression who is prescribed antidepressants. The patient reports to the nurse, "I have to drink a lot of water now as I am feeling very thirsty and I'm not able to pass urine properly." What does the nurse interpret from these observations?

The patient is experiencing side effects of amitriptyline. The patient with depression may be prescribed amitriptyline, which is a tricyclic antidepressant. The side effects of amitriptyline are dry mouth, urinary retention, and hypotension, which may make the patient crave water. If the patient is nonadherent to the medications, then the patient will have depressive symptoms, like loss of appetite and insomnia rather than dry mouth and urinary retention. Photosensitivity or rash would be indications of food-drug interaction. The side effects of norepinephrine and mirtazapine, or serotonin-specific antidepressants, include weight gain and sexual dysfunction rather than dry mouth. p. 260, Table 14.6

A patient and his or her spouse seek treatment for what they describe as severe depression. The spouse tells the nurse the patient goes on bouts of "wild gambling." The patient becomes excitable for days and eventually ends up losing large amounts of money. What can the nurse determine about this patient's depression?

The patient may have a condition other than major depression. One criterion for a diagnosis of major depressive disorder is the lack of a manic or hypomanic episode. The gambling episodes are more in line with the manic and compulsive traits seen in bipolar depression. This means it is not a typical case of major depressive disorder. Differentiating between depressive disorder and episodic depression is typically made based on frequency and duration. There is no mention of hallucinations or delusions, which is central to a diagnosis of schizophrenia. p. 245

A pastor who has training in psychotherapy is caring for a patient who does not believe in pharmacological treatments. On one visit, the patient tells the pastor that he or she wants to "return to heaven." The pastor knows the patient has firearms. What is the pastor's best course of action?

The patient requires emergency intervention. When a patient details a plan for suicide emergency intervention is required. This may include involuntary admission for observation. The pastor and patient may believe that suicide is a sin, but this may not be enough for a patient with disordered thinking. The pastor can involve the family if possible as part of emergency intervention. The pastor should do everything he or she can to stop the patient. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer. p. 248

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed patients on the unit are older than 60 years." The reply by the nurse that clarifies the prevalence of this disease is

"Depression is seen in people of all ages, from childhood to old age." Depression can occur at any age. Children, adolescents, adults, and the elderly may all experience depression. pp. 245-246

Which statement made by a depressed patient would provide insight into a common feeling associated with depression?

"I still feel bad about my sister dying of cancer. I should have done more for her!" Guilt is a common accompaniment to depression. A person may ruminate over present or past failings. Praying and reading the Bible describes a coping mechanism; wanting independence and feeling that depression is a weakness do not describe a common accompaniment to depression. p. 251

A patient diagnosed with chronic severe depression has been prescribed a series of electroconvulsive therapy (ECT) treatments. The nurse's initial intervention is to ask:

"Will you let me know if you want or need to talk about these ECT treatments?" An essential role of the nurse is to allow the patient an opportunity to express feelings, including concerns associated with myths or fantasies involving ECT. "Will you let me know if you want or need to talk about these ECT treatments?" does not present any barriers to communication and so allows the patient to express his or her feelings and concerns. The question about the nurse staying with the patient makes assumptions about the patient's concerns and so is a barrier to effective communication. The questions about helping the patient feel more comfortable and concerning the benefits and drawbacks of ECT make assumptions about the patient's needs and so are barriers to effective communication. p. 264

Which statements are associated directly with Beck's cognitive triad? (SATA)

-"I'm not worth much; I can't do anything right." -"Things will only get worse; they never get better." -"I'll never find anyone who loves or values me." Three assumptions constitute Beck's cognitive triad: (1) a negative, self-deprecating view of self; (2) a pessimistic view of the world; and (3) the belief that negative reinforcement (or no validation for the self) will continue in the future. Statements such as "I don't think other people are worthless" and "Good luck happens to good people" lack the negative assumptions associated with the cognitive triad. p. 248

Which child or teenager is demonstrating classic depression-related behavior? (SATA)

-A 4-year-old who cries frequently for no apparent physical reason -An 8-year-old who consistently declines offers to play with schoolmates -A 15-year-old who becomes verbally abusive to siblings As children grow and develop, they may display a wide range of moods and behaviors, making it easy to overlook signs of depression. For example, a very young child may cry, a school-age child might withdraw, and a teenager may become irritable in response to feeling sad or hopeless. The 6-year-old who demands to sleep with mom when dad is away and an 11-year-old who cries when a beloved family pet runs away are examples of acute grief or anxiety rather that depression. p. 252

Which antidepressant drug can be prescribed to depressed patients who also suffer from narrow-angle glaucoma? (SATA)

-Bupropion -Isocarboxazid -Tranylcypromine Bupropion is a norepinephrine dopamine reuptake inhibitor that can be prescribed to treat depression in patients with narrow angle glaucoma. It blocks the synaptic reuptake of norepinephrine and dopamine instead of the muscarinic receptors. Isocarboxazid is a monoamine oxidase inhibitor that inhibits the monoamine oxidase enzyme. It does not antagonize the muscarinic actions, so it can be prescribed to patients with narrow angle glaucoma. Tranylcypromine is a monoamine oxidase inhibitor. It does not cause side effects like blurred vision, so it is safe to be prescribed. Tricyclic antidepressants such as desipramine and amitriptyline must be avoided in depressed patients with narrow angle glaucoma. Tricyclic antidepressants are muscarinic receptor antagonists and thus cause blurred vision. These drugs would worsen the condition of narrow angle glaucoma. p. 261

A depressive patient with comorbid anxiety was prescribed vagus nerve stimulation (VNS). What appropriate teachings does the nurse give to the patient's family? (SATA)

-The nurse informs them about voice alteration. -The nurse advises "Turn off the device when needed." Vagus nerve stimulation (VNS) is a surgery in which a pacemaker is implanted into the left chest wall of the patient. Most of the patients may have voice alteration as a side effect, and they and their family should be informed about it. The patient should be advised to turn off the device when needed, such as during exercise. The device can be turned off by placing a special magnet over the implant. It is not necessary to keep the device on all the time. Side effects include neck pain, cough, paresthesia and dyspnea. The patient may not have paralysis or confusion. p. 265

While caring for a patient with HIV, the nurse finds that the patient is at risk for self-mutilation. Which symptoms would have led the nurse to this conclusion? (SATA)

-The patient has suicidal ideation. -The patient has a feeling of worthlessness. Comorbid depression can be seen in patients with HIV. Self-mutilation is a common indication of depression. It is characterized by feelings of worthlessness and suicidal ideation. Depression can cause a decrease in appetite and nutritional imbalance in the patient. However, a decreased appetite does not indicate a risk for self-mutilation. The patient not praying is not a symptom of risk for self-mutilation. The inability to perform a simple task indicates reduced concentration and interest. p. 251

A teenage patient was admitted several weeks ago after a suicide attempt. Despite family therapy, one of the parents is still struggling to cope with the child's behavior. Which teaching point would be most beneficial for the parents?

Depression is beyond voluntary control, but it can be managed. Family support is key to improving the prognosis for depressed teenagers. Crucial to this is the parents' understanding that depression is involuntary but can be managed. The patient should not stop taking prescribed medications without consulting the doctor. The patient does need to find ways to express feelings, but expressing anger is not always a solution. Depression can be hereditary, but this does not address the parent's concern. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. p. 255

A patient says to the nurse, "I had my first episode of depression after I got divorced about 10 years ago. I recognized what was happening to me because both of my parents suffer from depression." Which theory regarding the etiology of depression has the patient described?

Diathesis-stress model The diathesis-stress model of depression takes into account the interplay between genetic and biological predisposition toward depression and life events. The physiological vulnerabilities, such as genetic predispositions, biochemical makeup, and personality structure, are referred to as a diathesis. The stress part of this model refers to the life events that impact individual vulnerabilities. Cognitive theory recognizes the role of early life experiences in the development of depression. Biochemical factors include genetic and biological variables in the etiology of depression. Learned helplessness refers to a theory about depression replacing anxiety. p. 248

A nurse is teaching a group of nursing students about antidepressants that act by increasing the availability time of noradrenaline and serotonin at the postsynaptic receptors. Which medication would you expect to see prescribed?

Imipramine Imipramine belongs to the class of tricyclic antidepressants that act by increasing the availability time of noradrenaline and serotonin at the postsynaptic receptors. An increase in the serotonin and norepinephrine levels can cause mood elevation. Bupropion belongs to norepinephrine dopamine reuptake inhibitors. It blocks the synaptic reuptake of norepinephrine and dopamine. Vilazodone is a selective serotonin reuptake inhibitor and serotonin receptor agonist. It acts by blocking the synaptic reuptake of serotonin and activated serotonin receptors. Sertraline is a selective serotonin reuptake inhibitor. It blocks the synaptic reuptake of serotonin. p. 260, Table 14.6

A pregnant patient is diagnosed with seasonal affective disorder. What appropriate action does the nurse include in the patient's treatment plan?

Instruct the patient to get exposed to a light source for 30 to 45 minutes daily. Light therapy is the best treatment for seasonal affective disorder. It increases the melatonin secretion by the pineal gland. It is ideal to expose the patient to a light source for 30 to 45 minutes. It helps in elevating the mood of the patient with seasonal affective disorder. St. John's wort (Hypericum perforatum), though it is an herb, should not be given to pregnant patients as it may not be safe. Selective serotonin reuptake inhibitors must not be used as they may have teratogenic effects on the fetus. Exercise enhances the mood, so the nurse must encourage the patient to exercise regularly. p. 266

The nurse cares for an adult who repeatedly says, "My dead relatives try to talk to me and penetrate my body." This comment is most associated with which of the following disorders?

Major depressive disorder with psychosis Depressive disorders are classified according to symptoms or the situations under which they occur. During a major depressive episode, the person's ability to think clearly is negatively affected and evidence of delusional thinking may be seen. Delusional thinking is an aspect of psychosis. Seasonal affective disorder is characterized by marked seasonal differences in mood associated with decreased daylight. Substance-induced depressive disorder applies when symptoms of a major depressive episode arise in association with drug or alcohol intoxication or withdrawal. Disruptive mood dysregulation disorder relates to children and refers to situations in which a person has frequent temper tantrums, resulting in verbal or behavioral outbursts out of proportion to the situation. pp. 251-252

Beck's cognitive theory suggests that the etiology of depression is related to

Negative processing of information Beck is a cognitive theorist who developed the theory of the cognitive triad of three automatic thoughts responsible for people becoming depressed: (1) a negative, self-deprecating view of oneself; (2) a pessimistic view of the world; and (3) the belief that negative reinforcement will continue. p. 248

A depressed patient is noted to pace most of the time, pull at his or her clothes, and wring his or her hands. These behaviors are consistent with

Psychomotor agitation These behaviors describe the psychomotor agitation sometimes seen in patients with the agitated type of depression. p. 252

The nurse has developed a plan for a patient with a severe sleep pattern disturbance to spend 20 minutes in the gym exercising each afternoon. Which intervention should be scheduled upon returning to the unit?

Rest A depressed patient usually has little energy. After even a short exercise period, the patient may feel exhausted and need rest. p. 256, Table 14.5

What is the major reason for hospitalization for depressed patients?

Suicidal ideation Suicidal thoughts are a major reason for hospitalization for patients with major depression. It is imperative to intervene with such patients to keep them safe from self-harm. Inability to go to work, loss of appetite, and psychomotor agitation describe symptoms of major depression but are not by themselves the major reason for hospitalization. p. 248

An 8-year-old patient has been showing signs of disruptive mood regulation disorder, including irritability, tantrums, and anger. What other factor must be considered to confirm the diagnosis?

The symptoms must occur in two different settings. The symptoms of disruptive mood regulation disorder must occur in at least two separate settings, such as the home and school. The symptoms typically occur three or more times a week, not daily. Some children with this disorder manage to maintain control at school. Although family is most likely to notice symptoms, teachers and peers may notice them as well. p. 243

A patient admitted with a diagnosis of depression has been having angry outbursts with staff and peers on the unit since being admitted. Based on the patient's behavior, what is the nurse's primary concern?

This type of behavior places a depressed patient at high risk for self-harm. Overt hostility is highly correlated with suicide; therefore, the patient may be considered high risk, and appropriate precautions should be taken. There is no evidence to support encouraging the patient's new found assertiveness, the patient's transference, or that the patient is likely angry at someone else. p. 253

The nursing diagnosis of imbalanced nutrition—less than body requirements—has been identified for a patient diagnosed with severe depression. The most reliable evaluation of outcomes will be based on the patient's

Weekly weights The patient's body weight is the most reliable and objective evaluation of success in treating this nursing diagnosis. p. 156, Table 14.5

A patient diagnosed with depression admitted with suicidal ideation is prescribed amitriptyline. The patient asks, "Why did the health care provider give me a prescription for only seven days of this medication?" Based on the understanding of the medication, what is the nurse's reply?

"Amitriptyline is lethal in overdose, so this is a safety precaution." Amitriptyline is a tricyclic antidepressant (TCA); these drugs are known to be lethal in smaller doses than other antidepressants. Because the patient had a plan of overdose, the best course of action is to give a small prescription requiring the patient to visit the health care provider's office more often for monitoring of suicidal ideation and plan. Tricyclics are not known to be expensive. Antidepressant therapy usually takes several weeks to produce full results, so the patient would not be evaluated after only one week. Side effects are always a consideration, but not the most important consideration with TCAs. p. 260, Table 14.6

In a clinical study for a new antidepressant drug, the nurse was asked to select patients for the study. Which parameters should the nurse assess to include the patient in the study? (SATA)

-Serotonin levels -Cortisol levels in urine -Corticotrophin-releasing hormone Patients with depression have increased cortisol levels in the urine and elevated corticotrophin-releasing hormone. Depression is also caused due to the dysregulation of neurotransmitters, mainly serotonin levels. Blood pressure, urine output, and fluid intake levels are not related to depression. p. 247

A patient is prescribed tricyclic antidepressants. What should the nurse check for in the patient's case history before administering the drug?

Oral contraceptive use Medications such as oral contraceptives, antihypertensive reagents, monoamine oxidase inhibitors and anticoagulants may react with tricyclic antidepressants. It can cause potent side effects due to drug interaction. The nurse should check for their administration in the patient's case history and inform the primary healthcare provider. Suicidal ideation, loss of appetite, and insomnia are common symptoms of depression. p. 261

What will the nurse do to address the potential risk for depression among a population?

Routinely assess all chronically ill patients for depression during their admission interview. A high incidence of depression is found among all patients hospitalized for medical illnesses. These depressions are largely unrecognized and untreated by general health care providers. Studies suggest that about one third of medical inpatients report mild or moderate symptoms of depression and up to one fourth may have major depression. Chronic medical conditions often are associated with depression. A depression screening is becoming more common because research suggests the incidence of depression in school age children is significant. Presenting educational programs on depression to senior citizens is becoming more common because research suggests the incidence of depression in the older adult is significant. Including depression information to new mothers is becoming more common because research suggests the incidence of depression in postpartum women is significant. p. 267

A depressive patient is prescribed monoamine oxidase inhibitors. The nurse gives the diet chart to the patient. Which food does the patient consume according to the diet chart?

The patient eats yogurt. The patient eats yogurt as it contains less or no tyramine and is safe. Monoamine oxidase inhibitors (MAOIs) increase the levels of tyramine. So a patient on MAOIs should consume foods which have no or very low levels of tyramine, as an increase in tyramine levels can cause high blood pressure and hypertensive crisis. The patient avoids eating cheese, bananas, and dried fish as they contain high levels of tyramine. p. 262, Table 14.7