120 Unit 3

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse? "I will call your care provider. Perhaps you need a different medication." "Don't worry. We can try taking it at a different time of day to help it work better." "It usually takes a few weeks for you to notice improvement from this medication." "Your life is much better now. You will feel better soon."

"It usually takes a few weeks for you to notice improvement from this medication." (Seeing a response to antidepressants takes 3 to 6 weeks. No change in medication is indicated at this point of treatment, because there is no report of adverse effects from the medication. If nausea is present, taking the medication with food may help, but this is not reported by the patient, so a change in administration time is not needed. Telling a depressed patient that his or her life is better does not acknowledge the patient's feelings.)

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best address this cognitive distortion with which response? "Let's look at what you just said, that you can 'never do anything right.'" "Tell me what things you think you are not able to do correctly." "Is this part of the reason you think no one likes you?" "That is the most unrealistic thing I have ever heard."

"Let's look at what you just said, that you can 'never do anything right.'" (Cognitive distortions can be refuted by examining them, but to examine them the nurse must gain the client's willingness to participate. None of the other options examines the underlying cause of the feeling.)

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. "Posttraumatic stress disorder often changes a person's sexual functioning." "I encourage you to continue to participate in social activities where children are present." "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

"Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support." (Posttraumatic stress disorder precipitates changes that often lead to divorce. It's important to provide support to both the veteran and spouse. Confrontation will not be effective. While it's important to provide information, on-going support will be more effective.)

A soldier who served in a combat zone returned to the U.S. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with posttraumatic stress disorder (PTSD)? Reexperiencing Hyperarousal Avoidance Psychosis

Avoidance (Physiological reactions to reminders of the event that include persistent avoidance of stimuli associated with the trauma results in the individual's avoiding talking about the event or avoiding activities, people, or places that arouse memories of the trauma. Avoidance is exemplified by a sense of foreshortened future and estrangement. There is no evidence this soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not evident.)

The nurse is teaching a client who is receiving a monoamine oxidase inhibitor about dietary restrictions. The nurse plans to caution the client to avoid which foods? Pork, spinach, and fresh oysters Milk, grapes, and meat tenderizers Cheese, beer, and products with chocolate Leafy green vegetables, fresh apples, and ice cream

Cheese, beer, and products with chocolate (Cheese, beer, and products with chocolate are high in tyramine, which in the presence of a monoamine oxidase inhibitor can cause an excessive epinephrine-type response that can result in a hypertensive crisis. There is no relationship between monoamine oxidase inhibitors and pork, spinach, oysters, milk, grapes, meat tenderizers, leafy green vegetables, apples, or ice cream.)

An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment? There are no special preparations needed before this treatment. Common side effects include headache and short-term memory loss. One treatment will be needed to cure the depression. This treatment will leave you unconscious for several hours.

Common side effects include headache and short-term memory loss. (Common side effects of ECT include headache, sleepiness, short-term memory loss, nausea, and muscle aches. Preparations before and after the procedure are the same as any operative procedure involving the patient receiving anesthesia. Treatment is typically three sessions a week for 4 weeks, not once. Patients are not unconscious after the procedure due to the use of precisely placed electrodes and the use of anesthesia.)

A nurse plans a staff education program for employees of a senior living community. Which topic has priority? Late-onset schizophrenia Depression and suicide Dementia Delirium

Depression and suicide (Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence.)

Which change in the brain's biochemical function is most associated with suicidal behavior? Dopamine excess Serotonin deficiency Acetylcholine excess Gamma-aminobutyric acid deficiency

Serotonin deficiency (Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality.)

A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient? The medication dose needs to be decreased. Treatment is successful, and medication can be stopped. The patient is ready to return to work. Specific assessment for suicide plan must be evaluated.

Specific assessment for suicide plan must be evaluated. (Energy levels increase as depression lifts; this may increase the risk of completing a suicide plan. An increase in mood would not indicate a decrease or discontinuation of prescribed medication. The patient may be ready to return to work, but assessment for suicide risk in a patient who has had suicidal ideation is the priority assessment.)

A patient diagnosed with depression is receiving imipramine (Tofranil) 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? Dry mouth Blurred vision Nasal congestion Urinary retention

Urinary retention (All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.)

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to implement which intervention? Waiting quietly for the client to reply Prompting the client if the reply is slow Repeating the question if the client does not answer promptly Reviewing the client's medical record to support the client's response

Waiting quietly for the client to reply (Depressed clients think slowly and take long periods to formulate answers and respond. The nurse must be prepared to wait for a reply.)

Relaxation techniques help patients who have experienced major traumas because they: engage the parasympathetic nervous system. increase sympathetic stimulation. increase the metabolic rate. release hormones.

engage the parasympathetic nervous system. (In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal response damps down the sympathetic nervous system. This is a parasympathetic response with the heart rate and respiration slowing down and decreasing the blood pressure. Relaxation techniques promote activity of the parasympathetic nervous system.)

A 79-year-old white male tells a nurse, "I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing." The nurse should analyze this comment as: normal pessimism of the elderly. evidence of risks for suicide. a call for sympathy. normal grieving.

evidence of risks for suicide. (The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.)

A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, "This medicine isn't working." The nurse's best intervention would be to: discuss with the health care provider the need to increase the dose. reassure the patient that the medication will be effective soon. explain the time lag before antidepressants relieve symptoms. critically assess the patient for symptoms of improvement.

explain the time lag before antidepressants relieve symptoms. (Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.)

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: bring up the issue at the community meeting. calmly tell the patient, "You must bathe daily." avoid forcing the issue in order to minimize stress. firmly and neutrally assist the patient with showering.

firmly and neutrally assist the patient with showering. (When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.)

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: hypotensive shock. hypertensive crisis. cardiac dysrhythmia. cardiogenic shock.

hypertensive crisis. (Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.)

Two weeks ago, a soldier returned to the U.S. from active duty in a combat zone in Afghanistan. The soldier was diagnosed with posttraumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention? "It's good to be home. I missed my home, family, and friends." "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." "I want to continue my education, but I'm not sure how I will fit in with other college students."

"I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." (The correct response indicates the soldier is thinking about death and feeling survivor's guilt. These emotions may accompany suicidal ideation, which warrants the nurse's follow-up assessment. Suicide is a high risk among military personnel diagnosed with posttraumatic stress disorder. One distracter indicates flashbacks, common with persons with PTSD, but not solely indicative that further problems exist. The other distracters are normal emotions associated with returning home and change.)

A patient diagnosed with major depression 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? "I really doubt that one person can be blamed for all the bad things that happen." "Let's look at one bad thing that happened to see if another explanation exists." "You are being extremely hard on yourself. Try to have a positive focus." "Are you saying that you don't have any good things happen?"

"Let's look at one bad thing that happened to see if another explanation exists." (By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.)

A patient newly diagnosed with depression states, "I have had other people in my family say that they have depression. Is this an inherited problem?" What is the nurse's best response? "There are a lot of mood disorders that are caused by many different causes. Inheriting these disorders is not likely." "Current research is focusing on fluid and electrolyte disorders as a cause for mood disorders." "All of your family members raised in the same area have probably learned to respond to problems in the same way." "Members of the same family may have the same biological predisposition to experiencing mood disorders."

"Members of the same family may have the same biological predisposition to experiencing mood disorders." (Research is showing a genetic or hereditary role in the predisposition of experiencing mood disorders. These tendencies can be inherited by family members. Fluid and electrolyte imbalances cause many problems, but neurotransmitters in the brain are more directly linked to mood disorders. Mood disorders are not a learned behavior, but are linked to neurotransmitters in the brain.)

A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares." The nurse will advise the patient to: "Go to the nearest emergency department immediately." "Do not to be alarmed. Take two aspirin and drink plenty of fluids." "Take a dose of your antidepressant now and come to the clinic to see the health care provider." "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

"Take a dose of your antidepressant now and come to the clinic to see the health care provider." (The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.)

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? Select all that apply. A young adult bungee jumped from a bridge with a best friend. An 8-year-old child watched an R-rated movie with both parents. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

An adolescent was kidnapped and held for 2 years in the home of a sexual predator. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks. (PTSD usually occurs after a traumatic event that is outside the range of usual experience. Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a bus or elevator accident; or crime-related events, such being taken hostage. The common element in these experiences is the individual's extraordinary helplessness or powerlessness in the face of such stressors. Bungee jumps by adolescents are part of the developmental task and might be frightening, but in an exhilarating way rather than a harmful way. A child may be disturbed by an R-rated movie, but the presence of the parents would modify the experience in a positive way.)

What information should the nurse give to the family of a client who has had a dissociative episode? Dissociation is a method for coping with severe stress. Dissociation suggests the possibility of early dementia. Brief periods of psychotic behavior may occur. Ways to intervene to prevent self-mutilation and suicide attempts.

Dissociation is a method for coping with severe stress. (Childhood physical, sexual, or emotional abuse and other traumatic events are associated with adults experiencing dissociative symptoms. None of the other options are true.)

A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient? Serum blood levels must be regularly monitored to assess for toxicity. To prevent side effects, the medication should be administered as an intramuscular injection. Eating foods such as blue cheese or red wine will cause side effects. This medication class may only be used safely for a few days at a time.

Eating foods such as blue cheese or red wine will cause side effects. (MAOIs have serious food interactions when ingested with tyramine-containing foods such as aged or processed foods. Serum levels are routinely monitored when mood stabilizers such as lithium carbonate are prescribed. It is not necessary to administer this class intramuscularly. This medication takes several weeks to show effectiveness and should not be stopped abruptly; short-term use will not be effective.)

The gas pedal on a person's car stuck on a busy interstate highway, causing the car to accelerate rapidly. For 20 minutes, the car was very difficult to control. Afterward, this person's cortisol regulation was compromised. Which assessment finding would the nurse expect associated with the dysregulation of cortisol? Weight gain Flashbacks Headache Diuresis

Flashbacks (Cortisol is a hormone released in response to stress. Severe dissociation or "mindflight" occurs for those who have suffered significant trauma. The episodic failure of dissociation causes intrusive symptoms such as flashbacks, thus dysregulating cortisol. The cortisol level may go up or down, so diuresis and/or weight gain may or may not occur. Answering this question correctly requires that the student apply prior learning regarding the effects of cortisol.)

An adult outpatient diagnosed with major depression has a history of several suicide attempts by overdose. Given this patient's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? Amitriptyline (Elavil), a sedating tricyclic medication Fluoxetine (Prozac), a selective serotonin reuptake inhibitor Desipramine (Norpramin), a stimulating tricyclic medication Tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor

Fluoxetine (Prozac), a selective serotonin reuptake inhibitor (Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this patient's history of overdosing, it is important that the medication be as safe as possible in case she takes an overdose of her prescribed medication.)

What should the nurse consider when caring for clients who are at risk for suicide? A client who fails in a suicide attempt will probably not try again. Formal suicide plans increase the likelihood that a client will attempt suicide. It is best not to talk to clients about suicide, because it may give them the idea. Clients who talk about suicide are not planning it; they are using the threat to gain attention.

Formal suicide plans increase the likelihood that a client will attempt suicide. (A formal plan demonstrates determination, concentration, and effort, with conclusions already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and stimulate further acts. Verbalizing feelings may help reduce the client's need to act out. Many clients verbalize their suicidal thoughts as they are working on their decision and plan of action; a suicide attempt is not necessarily just to receive attention.)

A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? Calling parents Excessive crying Giving away sweaters Staying alone in dorm room

Giving away sweaters (Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.)

A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? Macaroni and cheese, hot dogs, banana bread, caffeinated coffee Mashed potatoes, ground beef patty, corn, green beans, apple pie Avocado salad, ham, creamed potatoes, asparagus, chocolate cake Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

Mashed potatoes, ground beef patty, corn, green beans, apple pie (The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.)

A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? Tomato juice Orange juice Hot tea Milk

Milk (Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.)

Because a severely depressed client has not responded to any of the antidepressant medications, the primary healthcare provider decides to try electroconvulsive therapy (ECT). What should the nurse do before the treatment? Have the client speak with other clients undergoing ECT. Give a detailed explanation of what to expect after the procedure. Limit the client's intake to a light breakfast on the days of the treatment. Provide emotional support while presenting a simple explanation of the ECT procedure.

Provide emotional support while presenting a simple explanation of the ECT procedure. (The nurse should offer support and use clear, simple terms to allay the client's anxiety. Having the client talk to ECT recipients may be too frightening or confusing to the client, and the nurse is responsible for educating the client. Severely depressed clients cannot retain long explanations. The client generally is kept on nothing-by-mouth status before ECT to prevent aspiration during the procedure.)

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with posttraumatic stress disorder (PTSD) is the soldier describing? Reexperiencing Hyperarousal Avoidance Psychosis

Reexperiencing (Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the traumatic events are often associated with PTSD. The soldier has described intrusive thoughts and visions associated with reexperiencing the traumatic event. This description does not indicate psychosis, hypervigilance, or avoidance.)

A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.) Risk for caregiver strain Impaired verbal communication Risk for injury Imbalanced nutrition, less than body requirements Ineffective coping Sleep deprivation

Risk for injury Imbalanced nutrition, less than body requirements Sleep deprivation (Risk for injury, poor nutrition, and impaired sleep are priority needs of the patient experiencing mania related to their impulsivity, inability to attend to activities of daily living such as diet and hygiene, and disruption of sleep. Caregiver strain is important to be addressed but is not a priority need on admission for the patient. Verbal communication improves when the mania is managed, and racing thoughts return to normal patterns. Ineffective coping will require stabilization of the acute phase along with cognitive therapy over time.)

A patient diagnosed with depression 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. Powerlessness Risk for suicide Stress overload Spiritual distress

Risk for suicide (A patient diagnosed with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.)

In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse's priority is to determine whether which nursing diagnosis applies to this patient? Risk for suicide related to recent deaths of significant others Anxiety related to sudden and abrupt lifestyle changes Social isolation related to loss of existing family Spiritual distress related to anger with God

Risk for suicide related to recent deaths of significant others (The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient's social isolation is important, but the risk for suicide has higher priority.)

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's best intervention. Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." Say to the wife, "Your husband's heart was so severely damaged that it could no longer pump." Say to the wife, "I will call the health care provider to discuss this matter with you." Hold the wife's hand in silence until the family arrives.

Say to the wife, "I understand you are feeling upset. I will stay with you until your family comes." (The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic responses provide comfort. The nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating.)

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition? Anxiety Seasonal affective disorder Medication side effects Antisocial personality

Seasonal affective disorder (Decreased exposure to sunlight in winter months can reduce the production of serotonin in the brain, leading to a type of depression termed seasonal affective disorder; this tends to resolve with the longer days and increased exposure to sun of spring and summer. There are not enough data to identify anxiety or signs linked to medication, which also tend to not resolve with seasons. Antisocial traits include isolation but also include behaviors of manipulation and lack of remorse in interpersonal relationships.)

A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing? Primary prevention Secondary prevention Tertiary prevention Modified prevention

Secondary prevention (Secondary prevention is aimed at early detection of problems, in this case, the identification of depression for early intervention. Primary prevention for mood disorders focuses on stress reduction and societal issues such as reducing poverty and racism. Tertiary prevention aims to reduce disability from a diagnosed condition; for mood disorders, this includes prevention of relapse and protection from harm. Modified prevention is not a recognized level of prevention, although prevention interventions may need to be adapted to meet specific individual situations.)

Major depression 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? Powerlessness Defensive coping Situational low self-esteem Disturbed personal identity

Situational low self-esteem (The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.)

Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. (Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding.)

An adult diagnosed with major depression 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 Relaxation training classes Desensitization techniques Use of complementary therapy

Social skills training (Social skill training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and development of a patient's support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.)

A patient being treated with paroxetine (Paxil) 50 mg po daily for depression 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 Urinary frequency Psychomotor retardation Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness

Vital signs Presence of abdominal pain and diarrhea Hyperactivity or feelings of restlessness (The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected.)

The nurse interviewing a patient with suspected posttraumatic stress disorder should be alert to findings indicating the patient: (select all that apply) avoids people and places that arouse painful memories. experiences flashbacks or reexperiences the trauma. experiences symptoms suggestive of a heart attack. feels driven to repeat selected ritualistic behaviors. demonstrates hypervigilance or distrusts others. feels detached, estranged, or empty inside.

avoids people and places that arouse painful memories. experiences flashbacks or reexperiences the trauma. experiences symptoms suggestive of a heart attack. demonstrates hypervigilance or distrusts others. feels detached, estranged, or empty inside. (These assessment findings are consistent with the symptoms of posttraumatic stress disorder. Ritualistic behaviors are expected in obsessive-compulsive disorder.)

Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: distracting the patient from self-absorption. careful unobtrusive observation around the clock. allowing the patient to spend long periods alone in meditation. opportunities to assume a leadership role in the therapeutic milieu.

careful unobtrusive observation around the clock. (Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.)

When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: psychoanalytic therapy. desensitization therapy. cognitive behavioral therapy. alternative and complementary therapies.

cognitive behavioral therapy. (Cognitive behavioral therapy attempts to alter the patient's dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.)

A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient: monitors sodium intake and weight daily. wears support stockings and elevates the legs when sitting. can identify foods with high selenium content that should be avoided. confers with a pharmacist when selecting over-the-counter medications.

confers with a pharmacist when selecting over-the-counter medications. (Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.)

A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend: (select all that apply) conveying empathy and acknowledging the child's distress. explaining and reinforcing reality to avoid distortions. using a calm manner and low, comforting voice. avoiding repetition in what is said to the child. staying with the child until the anxiety decreases. minimizing opportunities for exercise and play.

conveying empathy and acknowledging the child's distress. explaining and reinforcing reality to avoid distortions. using a calm manner and low, comforting voice. staying with the child until the anxiety decreases. (The child's symptoms and behavior suggest that he is exhibiting posttraumatic stress disorder. Interventions appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the child's distress, repeating content as needed when there is impaired cognitive processing and memory, providing opportunities for comforting and normalizing play and physical activities, correcting any distortion of reality, and staying with the child to increase his sense of security.)

Four teenagers died in an automobile accident. One week later, which behavior by the parents of these teenagers most clearly demonstrates resilience? The parents who: visit their teenager's grave daily. return immediately to employment. discuss the accident within the family only. create a scholarship fund at their child's high school.

create a scholarship fund at their child's high school. (Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings. Visiting the grave daily shows active continued mourning but is not as strongly indicative of resilience as the correct response.)

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." How should the nurse respond to this statement? "That is a good observation. Depression does mostly strike people older than 50 years." "Depression is seen in people of all ages, from childhood to old age." "Depression is most often seen among the middle adult age group." "The age of onset for most depressive episodes is given as 18 years."

"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.)

After the sudden death of his wife, a man says, "I can't live without her...she was my whole life." Select the nurse's most therapeutic reply. "Each day will get a little better." "Her death is a terrible loss for you." "It's important to recognize that she is no longer suffering." "Your friends will help you cope with this change in your life."

"Her death is a terrible loss for you." (Adjustment disorders may be associated with grief. A statement that validates a bereaved person's loss is more helpful than false reassurances and clichés. It signifies understanding.)

Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective? "They will put me to sleep during the procedure so I won't know what is happening." "I might be a little dizzy or have a mild headache after each procedure." "I will be unable to care for my children for about 2 months." "I will avoid eating foods that contain tyramine."

"I might be a little dizzy or have a mild headache after each procedure." (Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.)

A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient? "I will tell myself that I am a good person when things don't go well at work." "My medications will make my problems go away." "My family will help take care of my children while I am in the hospital." "This therapy will improve my response to neurotransmitter impulses."

"I will tell myself that I am a good person when things don't go well at work." (Cognitive therapy helps patients restructure their patterns of thinking to various events or thoughts in a more healthy way. Medication alters neurotransmitters but does not make problems go away. Family support is important but is not the goal of cognitive therapy. Neurotransmitters are affected by medication and brain stimulation therapy, not by cognitive therapy.)

Which statement would best show acceptance of a depressed, mute client? "I will be spending time with you each day to try to improve your mood." "I would like to sit with you for 15 minutes now and again this afternoon." "Each day we will spend time together to talk about things that are bothering you." "It is important for you to share your thoughts with someone who can help you evaluate your thinking."

"I would like to sit with you for 15 minutes now and again this afternoon." (Spending time with the client without making demands is a good way to show acceptance. While not inappropriate, the other options are less accepting.)

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? "Things will look brighter soon. Everyone feels down once in a while." "Our staff members care about you and want to try to help you get better." "It is difficult for others to care about you when you repeatedly say the same negative things." "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

"I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you." (Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is "offering self." Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.)

Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? Select all that apply. "Lately I have had a lot of aches and pains and just haven't felt very well." "People are in and out of my room all day and all night taking my things." "Don't ask me to eat. I can't because my stomach is upset all the time." "I'm eating more than usual, and I am sleeping about 6 hours a night." "Life seems more organized now that I don't live in my own home."

"Lately I have had a lot of aches and pains and just haven't felt very well." "People are in and out of my room all day and all night taking my things." "Don't ask me to eat. I can't because my stomach is upset all the time." (Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The distracters do not suggest symptoms of depression.)

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse? "The person may sleep more, have trouble completing hygiene needs, and have a poor appetite." "The person may have sudden spikes in blood pressure and crave foods that are sweet or salty." "The person may have excess energy, talk a lot, feel restless, and spend too much money." "The person may experience decreased energy and interest in activities beginning in the winter months."

"The person may have excess energy, talk a lot, feel restless, and spend too much money." (Signs that a person is cycling into a manic phase include sleeping and eating less and having increased energy and racing thoughts, increased impulsivity, and increased spending behaviors. Blood pressure may increase related to increased activity, but increased blood pressure and food cravings alone are not indicative of mania. Increased sleep and poor appetite and hygiene are indicative of depression. Decreased energy in winter seasons is indicative of seasonal affective disorder related to decreased sunlight.)

A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response. "Are you taking your medications the way they are prescribed?" "This loss is harder to accept because of your mental illness. Do you think you should be hospitalized?" "I'm worried about how much you are crying. Your grief over your husband's death has gone on too long." "The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings."

"The unexpected death of your husband is very painful. I'm glad you are able to talk about your feelings." (The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for a maladaptive response because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. Crying at 2 weeks after his death is expected and normal.)

A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment. "Are there any things going on in your life that would cause you to consider suicide?" "What are your beliefs about a person's right to take his or her own life?" "Do you think you are vulnerable to developing a depressed mood?" "If you felt suicidal, would you tell someone about your feelings?"

"What are your beliefs about a person's right to take his or her own life?" (This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.)

A nurse enters a depressed client's room on the evening of admission and observes the client sitting in a chair crying. What is the most therapeutic response by the nurse? "You're crying. Let's talk about it." "Let me get a cup of coffee; then we can talk." "Visitors will be here soon; you'd better get ready." "You'll feel better soon. Come to the sitting room with me."

"You're crying. Let's talk about it." (Noting that the client is crying and suggesting that the nurse and client talk about it addresses the behavior observed, and the offer by the nurse to spend time to help the client implies that the client is worthy. With "Let me get a cup of coffee; then we can talk" the nurse offers to help but places the client second by stating the desire to get coffee first. The nurse denies the client's feelings by focusing on getting ready for visitors. Assuring the client that the client will feel better soon and asking the client to come to the sitting room constitutes false reassurance. The nurse first recognizes the client's feelings and then moves away from discussing them.)

A patient diagnosed with major depression 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 look nice this morning." "You're wearing a new shirt." "I like the shirt you are wearing." "You must be feeling better today."

"You're wearing a new shirt." (Patients with depression usually see the negative side of things. The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other shirt." Neutral comments such as making an observation avoid negative interpretations. Saying, "You look nice" or "I like your shirt" gives approval (non-therapeutic techniques). Saying "You must be feeling better today" is an assumption, which is non-therapeutic.)

A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient? 0 to 0.5 mEq/L 0.6 to 0.9 mEq/L 1.0 to 1.4 mEq/L 1.5 or higher mEq/L

1.5 or higher mEq/L (Diarrhea, blurred vision, ataxia, and polyuria are all signs of lithium toxicity, which generally occurs at serum levels above 1.5 mEq/L. Serum levels within the normal range of 0.8 to 1.4 mEq/L are not likely to cause signs of toxicity.)

Which child is at greatest risk for developing attachment problems as a result of a neurobiological development? A 13-year-old male A 10-year-old female A 7-year-old male A 4-year-old female

A 4-year-old female (The developing brain is particularly vulnerable to adverse events because the most rapid brain development occurs in the first five years of life. The right hemisphere is involved in processing social-emotional information, promoting attachment functions, regulating body functions, and in supporting the individual in survival and in coping with stress. Since the right brain develops first and is involved with developing templates for relationships and regulation of emotion and bodily function, early attachment relationships are particularly important for healthy development and life-long health.)

A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? Select all that apply. Acute stress disorder Depersonalization disorder Generalized anxiety disorder Posttraumatic stress disorder Reactive attachment disorder Disinhibited social engagement disorder

Acute stress disorder Depersonalization disorder Posttraumatic stress disorder (Acute stress disorder, depersonalization disorder, and posttraumatic stress disorder can involve dissociative elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three disorders are also responses to acute stress or trauma, which has occurred here. The distracters are disorders not evident in this patient's presentation. Generalized anxiety disorder involves extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive attachment disorder and disinhibited social engagement disorder are problems of childhood.)

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 depressed; mood flat Affect flat; mood depressed Affect labile; mood euphoric Affect and mood are incongruent.

Affect flat; mood depressed (Mood refers to a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person's expression, the affect is flat.)

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." How should the nurse analyze this behavior? The comment suggests potential allegations of malpractice. In some cultures, grief is expressed solely through anger. Anger is an expected emotion in an adjustment disorder. The patient had ambivalent feelings about her husband.

Anger is an expected emotion in an adjustment disorder. (Symptoms of adjustment disorder run the gamut of all forms of distress including guilt, depression, and anger. Anger may protect the bereaved from facing the devastating reality of loss.)

As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient? Assess for depression and ask directly about suicidal thoughts. Ask the care provider to prescribe blood lab work to assess for depression. Focus on the presenting problems and refer the patient for a mental health evaluation. Interview the patient's family to identify their concerns about the patient's behaviors.

Assess for depression and ask directly about suicidal thoughts. (Assessing directly for thoughts of harm to self or others is a priority intervention for any patient exhibiting signs of a mental health disorder. It is estimated that 50% of individuals who succeed in suicide had visited a health care provider within the previous 24 hours. Currently there is no serum lab that identifies depression. The risk of self-harm is a priority safety issue that is monitored in all health care within the scope of the nurse. It is important to obtain information directly from the patient when possible, and then validate the information from family or other secondary sources.)

A child who was physically and sexually abused is at great risk for demonstrating which characteristic? Depression Suicide attempts Bullying and abusing others Becoming active in a gang

Bullying and abusing others (Children who have been abused are at risk for abusing others, as well as for developing dysfunctional patterns in close interpersonal relationships. While the other characteristics may occur, none are as characteristic as the correct option.)

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate? Loss of appetite Postural hypotension Complete temporary loss of memory Confusion immediately after the treatment

Confusion immediately after the treatment (The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of appetite, postural hypotension, and total amnesia are not usual or expected side effects.)

A patient states, "I feel detached and weird all the time. It is as though I am looking at life through a cloudy window. Everything seems unreal. It really messes up things at work and school." This scenario is most suggestive of which health problem? Acute stress disorder Dissociative amnesia Depersonalization disorder Disinhibited social engagement disorder

Depersonalization disorder (Depersonalization disorder involves a persistent or recurrent experience of feeling detached from and outside oneself. Although reality testing is intact, the experience causes significant impairment in social or occupational functioning and distress to the individual. Dissociative amnesia involves memory loss. Children with disinhibited social engagement disorder demonstrate no normal fear of strangers and are unusually willing to go off with strangers. Individuals with ASD experience three or more dissociative symptoms associated with a traumatic event, such as a subjective sense of numbing, detachment, or absence of emotional responsiveness; a reduction in awareness of surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the patient experiences only one symptom.)

A nurse works with a patient diagnosed with posttraumatic stress disorder who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? Trigger flashbacks intentionally in order to help the patient learn to cope with them. Explain that the physical symptoms are related to the psychological state. Encourage repression of memories associated with the traumatic event. Support "numbing" as a temporary way to manage intolerable feelings.

Explain that the physical symptoms are related to the psychological state. (Persons with posttraumatic stress disorder often experience somatic symptoms or sympathetic nervous system arousal that can be confusing and distressing. Explaining that these are the body's responses to psychological trauma helps the patient understand how such symptoms are part of the illness and something that will respond to treatment. This decreases powerlessness over the symptoms and helps instill a sense of hope. It also helps the patient to understand how relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of treatment for posttraumatic stress disorder is to come to terms with the event so treatment efforts would not include repression of memories or numbing. Triggering flashbacks would increase patient distress.)

A client prescribed a selective serotonin reuptake inhibitor mentions taking the medication along with the St. John's wort daily. The nurse should provide the client with what information regarding this practice? Agreeing that this will help the client to remember the medications. Caution the client to drink several glasses of water daily. Suggest that the client also use a sun lamp daily. Explain the high possibility of an adverse reaction.

Explain the high possibility of an adverse reaction. (Serotonin malignant syndrome is a possibility if St. John's wort is taken with other antidepressants. None of the other options are relevant to the situation.)

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? Arms crossed Staring at the nurse Smiling inappropriately Eyes pointed downward

Eyes pointed downward (Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.)

A soldier returned 3 months ago from Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). Which social event would be most disturbing for this soldier? Halloween festival with neighborhood children Singing carols around a Christmas tree A family outing to the seashore Fireworks display on July 4th

Fireworks display on July 4th (The exploding noises associated with fireworks are likely to provoke exaggerated responses for this soldier. The distracters are not associated with offensive sounds.)

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with posttraumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? Illusion Flashback Nightmare Auditory hallucination

Flashback (Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic event were recurring. Illusions are misinterpretations of stimuli, and although the experience is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this experience was stimulated by an actual environmental sound.)

Which measure would be considered a form of primary prevention for suicide? Psychiatric hospitalization of a suicidal patient Referral of a formerly suicidal patient to a support group Suicide precautions for 24 hours for newly admitted patients Helping school children learn to manage stress and be resilient

Helping school children learn to manage stress and be resilient (This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.)

Which behavior best supports the diagnosis of posttraumatic stress disorder (PTSD) in a 4-year-old child? Overeating Hypervigilance A drive to be perfect Passivity

Hypervigilance (PTSD in preschool children may manifest as irritability, aggressive or self-destructive behavior, sleep disturbances, problems concentrating, and hypervigilance. None of the other options are characteristic of PTSD in a young child.)

A student nurse caring for a patient diagnosed with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply. Imbalanced nutrition: less than body requirements Chronic low self-esteem Sexual dysfunction Self-care deficit Powerlessness Insomnia

Imbalanced nutrition: less than body requirements Sexual dysfunction Self-care deficit Insomnia (Vegetative signs of depression are alterations in body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than diagnoses associated with feelings about self. See relationship to audience response question.)

The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply. Channeling excessive energy Reducing guilty ruminations Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation

Instilling a sense of hopefulness Assisting with self-care activities Accommodating psychomotor retardation (Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.)

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

January (The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.)

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? Turning on the oven and letting gas escape into the apartment during the night Cutting the wrists in the bathroom while the spouse reads in the next room Overdosing on aspirin with codeine while the spouse is out with friends Jumping from a railroad bridge located in a deserted area late at night

Jumping from a railroad bridge located in a deserted area late at night (This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential.)

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse should identify this cognitive distortion as what response? Self-blame Catatonia Learned helplessness Discounting positive attributes

Learned helplessness (Learned helplessness results in depression when the client feels no control over the outcome of a situation. None of the other options demonstrate these feelings.)

A patient diagnosed with major depression 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. Ask the patient direct questions. Phrase questions to require yes or no answers. Frequently reassure the patient to reduce guilt feelings.

Make observations. (Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse's presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.)

A patient diagnosed with major depression 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. Eliminate all daily caffeine intake. Restrict intake of processed foods.

Offer laxatives if needed. Monitor food and fluid intake. Provide a quiet sleep environment. (The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.)

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? Onset of action is from 1 to 3 weeks or longer. They tend to be more effective for men. Recent memory impairment is commonly observed. They often cause the client to have diurnal variation.

Onset of action is from 1 to 3 weeks or longer. (A drawback of antidepressant drugs is that improvement in mood may take 1 to 3 weeks or longer. None of the other options provide correct information regarding antidepressant medications.)

A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? Select all that apply. Poor eye contact Increased fever Appetite changes Increased white blood cell count Slowed speech

Poor eye contact Appetite changes Slowed speech (Typical signs of depression include sleep disturbance; poor eye contact; loss of interest in events; guilt; decreased energy, speech, and concentration; appetite changes; and slowed motor movements. Increased fever and white blood cell count are indicative of infection, not depression.)

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? Protecting the client against any suicidal impulses Supporting the client's interest in the outside world Helping the client manage the concern for family members Reassuring the client that past behaviors are not being punished

Protecting the client against any suicidal impulses (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 soldier served in combat zones in Iraq during 2010 and was deployed to Afghanistan in 2013. When is it most important for the nurse to screen for signs and symptoms of posttraumatic stress disorder (PTSD)? Immediately upon return to the U.S. from Afghanistan Before departing Afghanistan to return to the U.S. One year after returning from Afghanistan Screening should be on-going

Screening should be on-going (PTSD can have a very long lag time, months to years. Screening should be on-going.)

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? Nutrition and hydration Supporting physiological stability Reducing disorientation and confusion Assisting the patient to identify and test negative thoughts

Supporting physiological stability (During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.)

A patient diagnosed with major depression received six electroconvulsive therapy 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. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. Temporary memory impairments and confusion may occur with electroconvulsive therapy. The patient needs time to readjust to a pressured work schedule.

Temporary memory impairments and confusion may occur with electroconvulsive therapy. (Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.)

Parents express concern when their 5-year-old child, who is receiving treatment for cancer, keeps referring to an imaginary friend, Candy. Which response should the nurse provide to best address the parent's concerns? Children of this age usually have imaginary friends. It is nothing to worry about unless the child starts to socially isolate. The child needs more of their one-on-one attention. The imaginary friend is a coping mechanism the child is using.

The imaginary friend is a coping mechanism the child is using. (Often traumatized children feel responsible for what happened to them and are frightened by flashbacks, amnesia, or hallucinations that may be due to trauma. For example, a child may use imaginary friends as a coping mechanism. This option addresses the parents' concern most effectively.)

Which statement about structural dissociation of the personality is true? An organic basis exists for this type of disorder. Nurses perceive clients with this disorder as easy to care for. No known link exists between this disorder and early childhood loss or trauma. This disorder results in a split in the personality causing a lack of integration.

This disorder results in a split in the personality causing a lack of integration. (The theory of structural dissociation of the personality proposes that patients with complex trauma have different parts of their personality, the apparently normal part and the emotional part, that are not fully integrated with each other. Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors. These different parts may not be aware of each other, with only one dominant personality operating depending on the situation and circumstance of the moment. None of the other options are accurate statements regarding this disorder.)

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? Feeling undeserving of the food Too busy to take the time to eat Wishes to avoid others in the dining room Believes that there is no need for food at this time

Too busy to take the time to eat (Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.)

A client diagnosed with post-traumatic stress disorder (PTSD) shows little symptom improvement after being prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse expects that which medication will be prescribed next? Beta blocker Barbiturate Tricyclic antidepressant (TCA) Sedative

Tricyclic antidepressant (TCA) (TCAs or mirtazapine (Remeron) may be prescribed if SSRIs or SNRIs are not tolerated or do not work. None of the other options would be the next consideration.)

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: dysthymia. anhedonia. euphoria. anergia.

anhedonia. (Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means "without energy.")

A nurse assessing an elderly patient for depression and suicide potential should include questions about mood as well as: (select all that apply) anhedonia. increased appetite. sleep pattern changes. evidence of grandiosity. increased concerns with bodily functions.

anhedonia. sleep pattern changes. increased concerns with bodily functions. (The correct responses relate to symptoms often noted in elderly patients with depression. Somatic symptoms are often present but missed by nurses as related to depression. Anorexia, rather than hyperphagia, occurs in major depression. Grandiosity is associated with bipolar disorder.)

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for: bipolar disorder. schizophrenia. depression. dementia.

depression. (Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders, and dissociative disorders. Incidence of the disorders identified in the distracters is similar to the general population.)

A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of: guilt and despair. over-involvement. interest and pleasure. ineffectiveness and frustration.

ineffectiveness and frustration. (Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient's progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient's resistance. Guilt and despair might be seen when the nurse experiences the patient's feelings because of empathy. Interest is possible, but not the most likely result.)

A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: restricting sodium intake to 1 gram daily. minimizing exposure to bright sunlight. reporting increased suicidal thoughts. maintaining a tyramine-free diet.

reporting increased suicidal thoughts. (Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.)

A patient diagnosed with major depression 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: limit the patient's activities to those that can be performed in a sitting position. withhold the drug, force oral fluids, and notify the health care provider. teach the patient strategies to manage postural hypotension. update the patient's mental status examination.

teach the patient strategies to manage postural hypotension. (Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing this information may convince the patient to continue the medication. Activity is an important aspect of the patient's treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.)

A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the child's parents have adapted to their loss? The parents: visit their child's grave daily. maintain their child's room as the child left it 2 years ago. keep a place set for the dead child at the family dinner table. throw flowers on the lake at each anniversary date of the accident.

throw flowers on the lake at each anniversary date of the accident. (Resilience refers to positive adaptation or the ability to maintain or regain mental health despite adversity. Loss of a child is among the highest-risk situations for an adjustment disorder and maladaptive grieving. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The other behaviors are maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the frequency of visiting the grave should have decreased.)

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). agree to take an antidepressant medication regularly by (date). initiate social interaction with another person daily by (date). identify two personal behaviors that alienate others by (date).

verbalize realistic positive characteristics about self by (date). (Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.)