Chapter 21: Depression
The mental health nurse appropriately provides education on light therapy to which client? A) 20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term B) 58-year-old showing signs of early Alzheimer's disease C) 45-year-old lawyer whose medication therapy needs an additional treatment D) 50-year-old farmer whose major depression has not responded to any treatment modality
A) 20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term Explanation: Phototherapy—or the exposure to bright artificial light—can markedly reverse the symptoms of seasonal affective disorder, which occurs in the fall and winter. Phototherapy would be most appropriate for a 20-year-old college student who reports being "too tired, sad, and unfocused" to enroll for classes in the winter term.
A client was abandoned by the parents at age 3, resulting in the client's perception of the world as a hostile place and the subsequent development of rage against men. This statement is an example of what? A) A psychodynamic interpretation of the client's major depressive disorder. B) A reason the client has become lesbian at the age of 23. C) A biological explanation for the client's depressive disorder. D) A feminist viewpoint of depression.
A) A psychodynamic interpretation of the client's major depressive disorder. Explanation: Psychodynamic theories postulate that clients with depression have unexpressed and unconscious anger about feeling helpless or dependent on others. Such anger begins in childhood when basic developmental needs are not met. Clients cannot express this anger toward the person or people on whom they feel dependent, so their anger turns inward.
A loss of pleasure or interest in a client diagnosed with depression would be documented as what? A) Anhedonia B) Flat affect C) Hopelessness D) Discouragement
A) Anhedonia Explanation: A person with depression has a sustained period of feeling depressed, sad, or hopeless and may experience anhedonia (loss of interest or pleasure). The client may report "not caring anymore" or not feeling any enjoyment in activities that were previously considered pleasurable. Flat affect is the complete or near absence of affective expression. Hopelessness and discouragement would not be the correct documentation for this symptom.
A nurse is caring for a client receiving a tricyclic antidepressant and is monitoring for anticholinergic side effects. Anticholinergic effects include which of the following? A) Blurred vision B) Hyperactive bowel sounds C) Urinary incontinence D) Moist skin
A) Blurred vision Explanation: Anticholinergic effects are prominent with tricyclic antidepressants. These include potentiation of central nervous system drugs, dry mucous membranes, warm and dry skin, blurred vision, decreased bowel motility, and urinary retention.
Which disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode? A) Dysthymic disorder B) Cyclothymic disorder C) Seasonal affective disorder D) Hypomania
A) Dysthymic disorder Explanation: Dysthymic disorder is characterized by at least 2 years of depressed mood for more days than not with some additional, less severe symptoms that do not meet the criteria for a major depressive episode. Cyclothymic disorder is characterized by 2 years of numerous periods of hypomanic symptoms that do not meet the criteria for bipolar disorder. Seasonal affective disorder occurs in the winter or spring. Hypomania is a period of abnormally and persistently elevated, expansive, or irritable mood lasting 4 days.
A client has no expression when conversing with the nurse. This would be documented as which type of affect? A) Flat B) Blunted C) Inappropriate D) Labile
A) Flat Explanation: Flat affect is absent or nearly absent affective expression. Blunted affect is a significantly reduced intensity of emotional expression. Inappropriate affect refers to discordant affective expression accompanying the content of speech or ideation. Labile affect is varied, rapid, and abrupt shifts in affective expression.
Which could be incorporated into the plan of care for a client receiving an antidepressant who is experiencing orthostatic hypotension? A) Increase hydration B) Take medication with food C) Get daily exercise D) Eat a nutritionally balanced diet
A) Increase hydration Explanation: Increasing hydration and sitting or standing up slowly are nonpharmacologic interventions for orthostatic hypotension. Taking medications with food would counteract nausea and vomiting. Daily exercise and eating a nutritionally balanced diet would help with weight gain that occurs in clients taking antidepressants.
A depressed older adult client is being treated with a tricyclic antidepressant (TCA). For which clinical manifestations should the nurse monitor the client? A) Orthostatic hypotension and urinary retention B) Photosensitivity and skin rashes C) Pseudoparkinsonism and tardive dyskinesia D) Diarrhea and electrolyte imbalance
A) Orthostatic hypotension and urinary retention Explanation: Orthostatic hypotension and urinary retention are common side effects of TCAs. Photosensitivity, skin rashes, pseudoparkinsonism, and tardive dyskinesia are common side effects of older antipsychotics. Diarrhea and electrolyte imbalances are side effects of lithium.
Carrie, age 20, was admitted to your unit following a suicide attempt. She is disheveled, disorganized, and dehydrated. The priority for her care during the first 24 hours of her admission is ... A) assessing Carrie's current suicidal ideation and putting her on suicide precautions. B) rehydrating Carrie by forcing fluids. C) assisting Carrie with her activities of daily living, including a shower and clean clothing. D) assessing Carrie's recent suicide attempt and identifying factors that may have contributed to it.
A) assessing Carrie's current suicidal ideation and putting her on suicide precautions. Explanation: The first step is to provide for Carrie's safety by assessing her risk for suicide. Because Carrie has attempted suicide, the nurse immediately places her on suicide precautions with frequent or continuous one-to-one observation and reassessment.
A client taking an antidepressant has experienced a 12-pound weight gain in 1 month as a side effect of the medication. Which of the following are nursing interventions to help this patient with this problem? Select all that apply. A) Advocate with the physician to consider changing the medication. B) Recommend a nutritionally balanced diet. C) Recommend daily exercise. D) Remind the patient that weight gain is better than feeling depressed. E) Reassure the patient that the weight gain is not that significant.
A, B, C . Explanation: To relieve the side effect of weight gain from an antidepressant, appropriate nursing interventions are to help the client explore a change in medication, promote a nutritionally balanced diet, and recommend regular exercise.
Which topics should the nurse explore when determining mental status during the psychosocial assessment process? Select all that apply. A) memory B) attention C) cognition D) mood and affect E) thought processes and content
A, B, C, D, E Explanation: The psychosocial assessment for persons who have major depressive disorder includes the mental status, coping skills, developmental history, psychiatric family history, patterns of relationships, quality of support system, education, work history, and impact of physical or sexual abuse on interpersonal function. Specific topics explored when determining the client's mental status include mood and affect, thought processes and content, cognition, memory, and attention.
A client taking a monoamine-oxidase inhibitor (MAOI) for depression should be instructed to avoid which of the following when taking the medication? Select all that apply. A) Aged cheese B) Beer C) Red meat D) Red wine E) Spinach
A, B, D Explanation: If co-administered with food or other substances containing tyramine (aged cheese, beer, red wine) MAOIs can trigger a hypertensive crisis.
Although its therapeutic mechanism of action is unknown, electroconvulsive therapy (ECT) is effective treatment for severe depression in some clients. The nurse is aware that ECT would be contraindicated in which of the following clients? A) Patients with increased intracranial pressure B) Patients who had recent myocardial infarctions (MIs) C) Patients who had acute renal failure D) Patients with recent cerebrovascular accidents (CVAs) E) Patients with recent retinal detachment F) Patients at risk for complications of anesthesia
A, B, D, E, F
A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action? A) Assess the client's blood pressure B) Perform a Mini Mental Status Examination (MMSE) C) Assess the client's jugular venous pressure D) Call an emergency code
Assess the client's blood pressure Explanation: Combining phenelzine with beer can precipitate a hypertensive crisis. There is no immediate indication that an emergency code is needed. The client's jugular venous pressure is less likely to be affected and is not a priority for assessment. Performing the MMSE is not a short-term priority.
The nurse reviews the medication list for a client who is newly prescribed a selective serotonin reuptake inhibitor (SSRI) for the treatment of depression. Which client statement indicates a need to assess the client for serotonin syndrome? A) "I stopped taking St. John's wort 4 weeks ago." B) "I started taking diet pills to assist with weight loss." C) "I stopped drinking red wine when I started taking my new prescription." D) "I used to enjoy taking ecstasy, but I know it isn't safe with my new medication."
B) "I started taking diet pills to assist with weight loss." Explanation: Serotonin syndrome is a potentially serious side effect caused by drug-induced excess of intrasynaptic serotonin, 5-hydroxytryptamine (5-HT). Combining medications that increase CNS serotonin levels, such as SSRIs + MAOIs, St. John's wort, diet pills, dextromethorphan, or alcohol (especially red wine) or an SSRI + street drugs (e.g., LSD, MMDA, or ecstasy). The client statement "I started taking diet pills to assist with weight loss." requires the nurse to assess the client for symptoms of serotonin syndrome, which include mental status changes, agitation, ataxia, myoclonus, hyperreflexia, fever, shivering, diaphoresis, and diarrhea. The other client statements do not indicate that the client is at risk for serotonin syndrome.
The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response? A) "Depression is a mood variation to life events." B) "The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present." C) "The physician diagnoses depression when a client has feelings of sadness several times a year." D) "Feelings of anxiety and sadness as a response to a life event are the most important qualifiers for depression."
B) "The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present." Explanation: Normal variations in mood (such as sadness, euphoria, and anxiety) occur in response to life events; they are time limited and not usually associated with significant functional impairment. The primary diagnostic criterion for major depressive disorder is one or more major depressive episodes (either a depressed mood or a loss of interest of pleasure in nearly all activities) for at least 2 weeks. Four of seven other symptoms must be present. Thus, the best response from the nurse is "the primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."
A client who is depressed begins to cry and states, "I'm just really sick of feeling this way. Nothing ever seems to go right in my life." Which would be the most appropriate response by the nurse? A) "Don't cry. Try to look at the positive side of things." B) "You are feeling really sad right now. It's a hard time." C) "Hang in there. Your medication will start helping in a few days." D) "Nothing ever goes right?"
B) "You are feeling really sad right now. It's a hard time." Explanation: Do not cut off interactions with cheerful remarks or platitudes. Do not belittle the client's feelings. Accept the client's verbalizations of feelings as real, and give support for expressions of emotions, especially those that may be difficult for the client (like anger). Allow (and encourage) the client to cry. It is important that the nurse does not attempt to "fix" the client's difficulties.
A client who was receiving a monoamine oxidase inhibitor (MAOI) is to be switched to a selective serotonin reuptake inhibitor (SSRI). The nurse would expect to begin administering the SSRI how many days after the MAOI is discontinued? A) 7 days B) 14 days C) 21 days D) 28 days
B) 14 days Explanation: To prevent possible interactions, 14 days should elapse between the discontinuation of the MAOI and the start of the SSRI.
A psychiatric-mental health nurse is working at a community mental health center that serves a large pediatric population. When assessing children for depression, which information would be most important for the nurse to keep in mind? A) Children commonly experience the same symptoms of depression as adults. B) Anxiety symptoms are more commonly noted in children who are depressed. C) The risk of suicide is low in children and adolescents. D) The mood observed in children with depression is more often sad than irritable.
B) Anxiety symptoms are more commonly noted in children who are depressed. Explanation: Children with depressive disorders have symptoms similar to those seen in adults with a few exceptions. They are more likely to have anxiety symptoms, such as fear of separation, and somatic symptoms, such as stomach aches and headaches. They may have less interaction with their peers and avoid play and recreational activities that they previously enjoyed. Mood may be irritable, rather than sad, especially in adolescents. In addition, the risk of suicide, which peaks during the midadolescent years, is very real in children and adolescents.
Which statement regarding depression and gender is correct? A) Depressive disorders are more common in men than women. B) Depressive disorders are more common in women than men. C) Depressive disorders equally affect men and women. D) Depressive disorders affect young men more than older women.
B) Depressive disorders are more common in women than men. Explanation: Depressive disorders are more prevalent in women than in men. Genetics, sociocultural factors, hormones, and other elements may account for this disparity.
A parent of four small children lost a spouse in an automobile accident 3 months ago and is admitted to the hospital with severe depression. Since the spouse's death, the client's mood has been somber; until now, the client has refused treatment. What is this client at high risk for? A) Bipolar disorder B) Suicide C) Schizophrenia D) Dysthymic disorder
B) Suicide Explanation: If depression persists over time and is left untreated, it has a significant negative effect on quality of life and increases the risk of suicide.
A client who otherwise is healthy is admitted for depression and reports feeling "all alone." The client reports recently losing a spouse to divorce. The client admits to drinking at least 12 beers every day. The client has which risk factors for the depression? Select all that apply. A) Medical comorbodity B) Current substance use or abuse C) Life and environmental stressors D) Lack of coping abilities E) History of depression
B, C, D Explanation: Risk factors for depression include prior history of depression, family history of depressive disorder, lack of social support, lack of coping abilities, presence of life and environmental stressors, current substance use or abuse, and medical comorbidity. This client's assessment findings include a recent life stressor in the form of divorce and excessive use of alcohol. In addition, the client's social isolation and heavy drinking indicate lack of healthy coping abilities. The client's data do not include a family history or prior history of depression or any other health issues.
A differential diagnosis for older clients is critical because symptoms of depression in this age group can be confused with symptoms related to which condition? Select all that apply. A) Pneumonia B) Dementia C) Urinary tract infection D) Cerebrovascular accident (CVA) E) Dehydration
B, D Explanation: Depressive symptomatology in this group may be confused with symptoms of dementia or CVA. Depression in older adults often is associated with chronic illness, such as heart disease, stroke, or cancer; symptoms may have a more somatic focus. Hence, differential diagnosis may be required to ascertain the root and cause of the symptoms.
A client with major depression is admitted to the health facility and expresses feelings of worthlessness and abandonment by significant others. Which replies by the nurse would convey empathy? A) "I can understand what is going on with you." B) "Are you feeling like others have abandoned you?" C) "It sounds like this is a really difficult time for you." D) "Can you tell me what you are thinking right now?"
C) "It sounds like this is a really difficult time for you." Explanation: "It sounds like this is a really difficult time for you" is an empathetic response that signifies that the nurse understands the client's ideas and feelings. Stating "I can understand what is going on with you" blocks effective communication because the nurse is minimizing the client's feelings. It indicates that the nurse cannot empathize with the client. Asking about if the client feels abandoned names the feelings and does not convey empathy. Asking what the client is thinking is not an empathetic response but is a therapeutic technique called exploring.
A client taking paroxetine reports to the nurse that they are experiencing nausea since beginning the medication. Which is the best response by the nurse? A) "Stop the medication for a few days to see if the nausea goes away." B) "This is an expected side effect that will improve with time." C) "Take the medication with food or a light snack." D) "Contact the health care provider for a change in medication."
C) "Take the medication with food or a light snack." Explanation: Taking selective serotonin reuptake inhibitors with food usually eliminates nausea. There is a delayed therapeutic response to antidepressants. The client should not stop taking the drug. It would be appropriate to reassure the client that this is an expected side effect that will improve with time, but that would not be done initially. A change in medication may be indicated if the nausea is intolerable or persistent, but that would not be done initially.
A 46-year-old client comes to the community mental health center because the client thinks they might be suffering from depression. When assessing this client, which symptom would the nurse identify as being necessary for the diagnosis of major depressive disorder to be made? A) Euphoria along with poor decision making ability B) Disregard for personal hygiene including cleanliness and appearance C) A loss of interest or inability to derive pleasure for previously enjoyed activities D) A stooped posture and nonverbal signs of a depressed mood
C) A loss of interest or inability to derive pleasure for previously enjoyed activities Explanation: Clients with major depressive disorder must have either a depressed mood or a loss of interest or inability to derive pleasure from previously enjoyed activities for diagnosis.
A nursing student is caring for an elderly client who is taking sertraline for depression. The instructor quizzes the student about the medication and its actions. To what classification of drugs should the student assign sertraline? A) Cyclic antidepressant B) Monoamine-oxidase inhibitor C) Selective serotonin reuptake inhibitor D) Serotonin 2 antagonist
C) Selective serotonin reuptake inhibitor Explanation: Sertraline is a selective serotonin reuptake inhibitor.
When completing a baseline assessment of a client with depression, which diagnostic tests would the nurse anticipate? A) Renal function tests B) Coagulation profile C) Thyroid function tests D) Abdominal ultrasound
C) Thyroid function tests Explanation: A physical examination is recommended with baseline vital signs and baseline laboratory tests, including a comprehensive blood chemistry panel, complete blood counts, liver function tests, thyroid function tests, urinalysis, and electrocardiograms. These physical examinations can help to rule out any underlying medical conditions that may be causing or exacerbating an existing depression. The other diagnostic tests indicated in the options are not related to identifying underlying medical conditions that are commonly found co-morbid to depression.
The psychiatric-mental health nurse is working with a group of older adults diagnosed with depression. Which client would the nurse identify as being at highest risk for suicide? A) 61-year-old B) 69-year-old C) 72-year-old D) 79-year-old
D) 79-year-old Explanation: Suicide is a very serious risk for older adults, especially men. Suicide rates peak during middle age, but a second peak occurs in those age 75 years and older.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority? A) Hopelessness related to recent divorce B) Ineffective coping related to inadequate stress management C) Spiritual distress related to conflicting thoughts about suicide and sin D) Risk for suicide related to highly lethal plan
D) Risk for suicide related to highly lethal plan Explanation: Safety is the priority. The overall goals for the client who is suicidal is first to keep the client safe and later to help him or her develop new coping skills that do not involve self-harm. Hopelessness related to recent divorce, ineffective coping related to inadequate stress management, and spiritual distress related to conflicting thoughts about suicide and sin would not be the priority diagnosis for this client.
A psychiatric-mental health nurse is conducting a pharmacology review class for a group of nurses. The topic is antidepressant medications. The nurse determines that the review was successful when the group identifies which class of antidepressant as associated with fewer side effects? A) Tricyclic antidepressants (TCAs) B) Monoamine oxidase inhibitors (MAOIs) C) Serotonin norepinephrine reuptake inhibitors (SNRIs) D) Selective serotonin reuptake inhibitors (SSRIs)
D) Selective serotonin reuptake inhibitors (SSRIs)
A nurse is assessing a client with depression. During the assessment, the nurse notes that the client's emotional expression does not match what the client is saying. The nurse would document this as which type of affect? A) Blunted B) Flat C) Incongruent D) Labile
Incongruent Explanation: An incongruent affect is a discordant affective expression accompanying the content of speech or ideation. A blunted affect is significantly reduced in intensity. A flat affect is characterized by an absent or nearly absent emotional expression. A labile affect is one that is varied, rapid, and abruptly shifts.
A client with major depression is scheduled to receive electroconvulsive therapy. The nurse understands that this treatment is typically used in which situation? A) The client is tolerating the initial drug therapy. B) The level of depression is mild to moderate. C) The client is experiencing catatonia. D) Suicidality is of little concern.
The client is experiencing catatonia. Explanation: Electroconvulsive therapy is an effective treatment for clients with severe depression. It is generally reserved for those whose disorder is refractory or intolerant to initial drug treatments and who are so severely ill that rapid treatment is required (e.g., clients with malnutrition, catatonia, or suicidality).
The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ... A) assess for depression in the client's family history. B) prepare the client for diagnostic genetic testing to confirm the diagnosis. C) educate the client regarding the symptoms of related physical disorders. D) encourage the client to seek genetic counseling before considering a pregnancy.
assess for depression in the client's family history. Explanation: The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should assess for depression in the client's family history.
