NU371 HESI Case Study: Major Depressive Disorder
During the conversation with the nurse on the clinic's emergency line, the client tells the nurse about thoughts of taking an overdose. The client tells the nurse about having prescriptions for lorazepam and bupropion. The nurse knows that an overdose of this combination of drugs could be lethal.
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Eight months after being discharged from the clinic, the client calls the clinic and wants to talk.
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Several days after starting the medication, the client calls the office and tells the nurse that the bupropion is causing headaches.
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Six months after the initial presentation, the client comes to the clinic for a regular visit. While waiting to be seen, the client tells the nurse about wanting to stop taking the medication.
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The client is admitted to the hospital for 5 days. Two weeks after discharge, the client returns to the mental health clinic for a follow-up visit. The APRN-PMH has prescribed 10 mg escitalopram at bedtime and 150 mg bupropion in the morning.
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The client meets with the nurse. During the group session, the client tells the nurse about an extreme amount of stress at work. The client has filed multiple harassment complaints against the boss. The client states feeling it is necessary to hold self to a higher set of standards than coworkers because their boss uses a stricter set of standards for the client's performance appraisal.
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The client states that she is worried that she is being singled out, because she is the oldest of her coworkers and believes that everyone thinks she should be doing better because of her age.
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The client tells the nurse about believing in doing a job right. The client goes on to say that the boss is discriminating because of age. The nurse further inquires about the statements made by the client about feeling regarding the work environment.
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The client tells the nurse about sweating all the time and occasional chest pains, plus numbness in arms and hands.
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While the nurse is teaching the client about taking bupropion, the client asks if it is all right to drink alcohol when taking the medication.q
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Although lorazepam is ordered as 0.5 mg, when the client goes to the pharmacy to pick up the prescriptions, the lorazepam is only available as 1 mg scored tablets at this time. How many tablet(s) should the nurse instruct the client to take with each dose? (Enter numerical value only. If rounding is necessary, round to the tenth.)
0.5
Planning
During the interview, the client identifies intense anxiety, irritability, and feelings of depression with thoughts of suicide as reasons for seeking treatment. The nurse develops a plan of care to assist the client in managing anxiety.
Which nursing diagnosis should the nurse add to the client's plan of care? a) Feeling powerless related to work conflict. b) An alteration in sensory perception related to false beliefs about being singled out. c) An alteration in body image related to permanent change in body due to aging. d) Feeling socially isolated related to work tension.
a) Feeling powerless related to work conflict. - The nurse can work with the client to feel more empowered to change own behavior and responses to the boss and coworkers. For example, the client may become more assertive or may decide to change jobs.
Which is the most important information the nurse should obtain from the client? a) If the client has a plan and means to harm self. b) The client's desire to carry out a suicide plan. c) Ask the client if there is anyone there with them. d) Discuss with the client ways to make sure not to cause self harm.
a) If the client has a plan and means to harm self. - When assessing for suicidal ideation, the nurse must first determine if the client has a means to harm themselves, then the true desire to do self-harm. The second phase of suicide prevention involves making a no-self harm plan. Lastly, the presence/absence of a support system is useful information.
Which nursing concerns would take priority when developing the client's care plan? (Select all that apply. One, some, or all responses may be correct.) a) Severe anxiety. b) Self-care deficit. c) Possibility of harming self. d) Having difficulty in coping. e) Difficulty communicating verbally.
a) Severe anxiety. c) Possibility of harming self. d) Having difficulty in coping.
During the initial assessment, the nurse should focus on which areas that are most characteristic of anxiety? (Select all that apply. One, some, or all responses may be correct.) a) Symptoms restlessness, difficulty concentrating, irritability. b) Social interactions such as withdrawal, shunning family, and drinking alcohol. c) Increasing symptoms of depression with consistently sad, low mood. d) Behavioral alterations including hallucinations. e) Suicidal ideation.
a) Symptoms restlessness, difficulty concentrating, irritability. c) Increasing symptoms of depression with consistently sad, low mood. e) Suicidal ideation.
Before the client has the prescription for bupropion filled, the nurse should ensure that the client has not experienced which problem(s)? (Select all that apply. One, some, or all responses may be correct.) a) Tachycardia. b) Anorexia or bulimia. c) Peptic ulcer disease. d) Hypertension. e) Seizures.
b) Anorexia or bulimia. e) Seizures.
What is the most important intervention the nurse should do once the client is taking the medication bupropion? a) Have the client report the level of anxiety since on the increased bupropion. b) Ask the client if there have been any suicidal thoughts since starting bupropion. c) Get the client to explain any improvement in energy since increasing the bupropion. d) Evaluate how much improvement the client feels has occured since starting the bupropion.
b) Ask the client if there have been any suicidal thoughts since starting bupropion. - Assessment for being a danger to oneself or others is always the first priority when assessing the depressed client.
Which statement by the client best suggests that the medication combination and therapy are working? a) The client reveals having more success at getting things done. b) The client states that the things that happen at work no longer bother her. c) The client states that thinking about committing suicide was a stupid thing. d) The client reports that the next time a feeling of hopelessness occurs, the first step will be to call the clinic.
b) The client states that the things that happen at work no longer bother her. - This statement suggests that the client's initial complaints have been resolved.
What information should the nurse discuss with the client about bupropion? a) Take at bedtime. b) May cause hand tremors. c) Anxiety level may increase. d) Use every other day.
c) Anxiety level may increase. - Clients who suffer from anxiety may experience increased agitation when taking this antidepressant.
Which statement by the nurse is most likely to encourage the client to talk about the issues that are contributing to the anxiety? a) Explain what age has to do with anxiety. b) Have client state what they think about current age. c) Ask the client about the meaning of being a certain age. d) Encourage the client to express what age means to the boss.
c) Ask the client about the meaning of being a certain age. - This question encourages the client to explore the relationship between age and level of anxiety.
The nurse recognizes that the client is experiencing what level of anxiety? a) Mild b) Moderate c) Severe d) Panic
c) Severe - The individual with severe anxiety can only focus on a narrowed area of concern, such as the client only focusing on her employer and coworkers.
Which behavior should the nurse encourage from the client? a) Participate in developing a plan for managing anxiety. b) Identify physical symptoms of stress. c) State the sources for present anxiety. d) Express the relationship between anxiety and stressors.
c) State the sources for present anxiety. - The nurse must understand the client's perception of the sources of her anxiety in order to help the client.
What makes termination important to the nurse-client relationship? a) Termination prevents further episodes of depression. b) Saying good-bye allows for release of feelings of loss. c) Termination summarizes the goals and objectives attained. d) Those with mental illness have difficulties with termination.
c) Termination summarizes the goals and objectives attained. - This is an opportunity for the client to discuss ways to incorporate new coping strategies learned while in treatment with the nurse.
Which statement by the client is the nurse basing this assessment? a) The client expresses thinking the boss does not like anyone with seniority. b) The client explains about working harder than ever to make the boss happy. c) The client describes tells the boss that nothing the boss does will cause distress anymore. d) The client states about not caring anymore about what the boss does to upset those in the office.
c) The client describes tells the boss that nothing the boss does will cause distress anymore. - This is reaction formation, a type of defense mechanism that occurs when clients turn their feelings or impulses into their opposites, such as the client's statement about the boss.
Which approach is best for the nurse to use when assessing a client's risk for attempting suicide? a) Tell the client to express which specific stress causes anxiety. b) Find out from client how is their social life at work and at home. c) Have the client explain what causes worse feelings. d) Ask the client about having a plan to harm self.
d) Ask the client about having a plan to harm self. - Assessment of suicidal intent and determining if there is an actual, viable plan is the most important component of client assessment and care plan development.
The nurse knows that the client is still easily upset by the boss's behavior. How should the nurse respond to the client? a) Instruct the client to explain plans on how to interact with the boss. b) Try to relate what going back to work with the boss is like for the client. c) Reiterate that the client did not report any concerns about the boss in the prior conversations. d) Ask the client to express what feelings occur when talking to the boss about something of concern.
d) Ask the client to express what feelings occur when talking to the boss about something of concern. - The nurse is encouraging the client to focus on feelings to be able to recognize when stressful events occur and deal with the feelings.
The orientation phase of building the therapeutic relationship is important to the establishment in which rapport can grow. Which approach is best for the nurse to use when assessing for subjective information from the client? a) Have the client say what is causing the anxiety. b) Tell the client that it sounds like the anxiety is causing depression. c) Get the client to explain how anxiety affects normal activities. d) Ask the client to give an example of how they feel when they are anxious.
d) Ask the client to give an example of how they feel when they are anxious. - This statement of asking for an example can clarify vague statements made by a client with anxiety .
How should the nurse respond to the client's question? a) Consuming wine or beer in moderation is all right. b) In moderation, alcohol has no interaction with bupropion. c) The client has to make the decision about whether to drink alcohol. d) Do not consume alcohol while taking this medication or it can cause seizures.
d) Do not consume alcohol while taking this medication or it can cause seizures. - Alcohol should not be consumed when taking the medication because it may increase the risk of seizures.
How should the nurse respond to the client? a) Inform the client of concern regarding safety and call the police. b) Contact the client's family to tell them what the client is saying. c) Tell the client to get rid all that medication by flushing it down the toilet. d) Express concern and determine if someone can take the client to the hospital.
d) Express concern and determine if someone can take the client to the hospital. - At this point, the client should be assessed for possible hospital admission. Determining if someone is available to transport the client reduces the likelihood that the client will drive while feeling suicidal.
How should the nurse respond to the client's comments? a) Tell the client that these issues are probably due to anxiety. b) Ask the client about the most recent check-up. c) Distract the client from worrying about these symptoms right now. d) Have the client elaborate on experiencing chest pain.
d) Have the client elaborate on experiencing chest pain. - It is important for the nurse to understand the client's perception of the problems before making further recommendations.
How should the nurse respond to the client's statement? a) Reiterate that the client that this is a lifelong medication. b) Tell the client to talk to the HCP about stopping the medicine. c) Inform the client that the medication can be stopped now if desired. d) Instruct the client that most clients do better by taking the medicine for months.
d) Instruct the client that most clients do better by taking the medicine for months. - It may take at lease 12 weeks for therapeutic effcts. Client's should be encouraged to continue their medication as prescribed.
How should the nurse respond to the client's request? a) Terminate the call as quickly as possible. b) Allow the client to talk as much as needed. c) Keep the conversation focused on superficial topics. d) Instruct the client to make an appointment for follow-up.
d) Instruct the client to make an appointment for follow-up. - The client should be encouraged to make an appointment so the client can discuss in depth the problems currently occurring. During the appointment, the need to reestablish care and a therapeutic relationship can be determined.
How should the nurse respond to the client's report of headaches? a) Interview the client for any other physical problems. b) Explain that the headaches usually go away within a few days. c) Ask the client about taking the medication daily at the same time. d) Tell the client that this medication may cause clients to have headaches.
d) Tell the client that this medication may cause clients to have headaches. - Headaches are a common side effect.
Crisis Intervention
After 4 weeks of therapy, the client calls the clinic's emergency line, crying and reports that there is nothing to live for.
Meet the Client
A client presents to the community mental health clinic. The client is divorced with no children. Job responsibilities include significant traveling. The client was working in the office this week and witnessed the collapse of a 6-story office building. The death toll from the collapse of that building was over 100. The client's medical history includes hypothyroidism and depression. The client tells the nurse about feeling increasingly depressed for a long time, easily irritated, anxious, and as someone who does not enjoy normal activities.
Outcomes
It has now been 1 year since the client's initial presentation to the clinic and the nurse is conducting a regular follow-up interview, listening as the client describes the situation at work. The nurse recognizes that the client is using reaction formation as a defense mechanism.
Medications
The APRN-PMH changes the client's antidepressant to bupropion 300 mg once a day and orders lorazepam 0.50 mg twice a day prn for the client's anxiety. When picking up the prescription at the front desk the client asks the nurse about the medications.
The nurse is concerned about the client's apparent continuing difficulties with the boss.
The client is discharged from the clinic program after 6 additional months of treatment. The client can recognize the aspects of work that cause anxiety and is able to deal with these problems appropriately. The nurse-client relationship is terminated with the client's discharge from the mental health clinic.
Assessment
The triage nurse performs a more in-depth assessment of the client's complaints and reports the assessment to the Advanced Practice Registered Nurse in Psychiatric-Mental Health (APRN-PMH). These two nurses collaborate on development of the care plan to facilitate assessment and interventions for the client's anxiety.