COMBINED NCLEX depressive disorders (some mood disorders)

A patient has a lithium level of 1.1 mEq/L. This level is 1. below the therapeutic level 2. above the therapeutic level 3. within the therapeutic range 4. not needed as lithium does not require blood levels

3. within the therapeutic range.

What percentage of people can expect to have a 2nd episode of MDD or DD after 5 years?

70%

Which food selection best meets the needs of the manic patient? 1. Pineapple, bananas, popcorn 2. Chicken and Mashed potatoes 3. Corn chowder and spinach 4. Peanut butter sandwich and carrots

4. peanut butter sandwich and carrots

Which activity has a calming effect on the manic patient? 1. writing on a notepad 2. reading a book 3. discussion of current events 4. watching a movie

4. watching a movie

Which patient statement indicates learned helplessness? 1. "I am a horrible person." 2. "Everyone in the world is just out to get me." 3. "It's all my fault that my husband left me for another woman." 4. "I hate myself."

"It's all my fault that my husband left me for another woman."

What do tricyclic antidepressants do?

-increase norepinephrine

signs and symptoms of serotonin symdrome

-musculoskeletal changes -fever -elevated BP -severe could result in death

Psychotic features

Indicates the presence of disorganized thinking, delusions or hallucinations

MAOI

NARDIL PARNATE MARPLAN EMSAM patch

Risk Factors for developing Bipolar disorder

Twins-more on mother's side unstable levels of norepinepherine, epinepherine and serotonin Stressful life events loss events Children who have mother or father with depression

Atypical antidepressants & SIDE EFFECTS

WELLBUTRIN-Bupropion CYMBALTA-Duloxeline EFFEXOR-venlafaxine REMERON-mirtazepine DESYREL-trazedone Remeron turns off appetite control center

mood

a feeling state reported by the client that can vary with internal and external changes

The nurse is talking to an adolescent about the death of his father 2 years ago. Which statement indicates a healthy progression in resolving this loss? a. I never really had any feelings about his death. b. I drive my father's old car which is nearly broken down, but I cannot give it up as it reminds me of him. c. I still can barely make it through the day without sobbing d. Of course I loved my father, but he was not perfect.

d. of course i loved my father, but he was not perfect

A female patient tells the nurse that she would like to begin taking St. John's Wort for depression. What teaching should the nurse provide? 1. "St. John's wort should be taken several hours after your other antidepressant." 2. "St. John's wort has generally been shown to be effective in treating depression." 3. "This supplement is safe to take if you are pregnant." 4. "St. John's wort is regulated by the FDA, so you can be assured of its safety."

"St. John's wort has generally been shown to be effective in treating depression."

Some other common diagnoses for individuals with depression

-Disturbed thought processes -Chronic low self-esteem -Imbalanced nutrition -Constipation -Disturbed sleep pattern -Ineffective coping -Spiritual distress -Disabled family coping

4 types of bipolar spectrum disorders

-Bipolar I -Bipolar II -cyclothymia -Bipolar disorder - not otherwise specified

What are some key points with depression in the young?

-Children as young as 3 years of age have been diagnosed with depression. -MDD may occur in 18% of preadolescents. -MDD among adolescents is often associated with substance abuse and antisocial behavior.

stages of grieving:

Denial Anger Bargaining Depression/resignation Acceptance

co-morbidity

co-occurance

It is likely that a client diagnosed with seasonal affective disorder will begin to experience fewer symptoms in the fall. winter. spring. summer.

spring. Seasonal affective disorder occurs during the months when sunlight diminishes. Clients may begin to feel effects in the late fall and will be affected throughout the winter. They improve during the spring and feel well during the summer.

An statement that would show acceptance of a depressed, mute client would be "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.

ECT is indicated if

-Patient is suicidal or homicidal. -Agitation or stupor is extreme. -Life-threatening illness is a result of the refusal of foods or fluids. -History includes a poor drug response or a good ECT response. -Standard medical treatment has no effect. -Major depression with psychotic symptoms

What are some key points with bipolar disorder in the young?

-Young S&S irritable, impulsive, aggressive, risk taker & hostile -Approx 1% lifetime prevalence -Frequently have rapid cycling -Thinking usually grandiose & illogical -Treatment: many require long-term or lifelong psychopharmacology

cyclothymic disorder

-alternating hypo-mania and depressive episodes - involves cycling between highs and lows, but it never reaches full mania or major depression

Bipolar I disorder

-at least one episode of mania alternating with major depression -psychosis may accompany manic episode

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? 1 Protecting the client against any suicidal impulses 2 Supporting the client's interest in the outside world 3 Helping the client manage the concern for family members 4 Reassuring the client that past behaviors are not being punished

1 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.

During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1 Lethargy 2 Ambivalence 3 Emotional lability 4 Increased appetite 5 Long periods of sleep

1,2,3 Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is associated with depression.

vegetative signs of depression

1. Change in bowel movement pattern (constipation) 2. Eating habits (anorexia) 3. Sleep 4. Disinterest in sex

In communicating with a patient who is experienceing an elated mood, which of the following interventions by the nurse is most approptriate: 1. use a calm, firm approach 2. Give expanded explanations 3. Make use of abstract concepts 4. Encourage lighthearted optimisim

1. use a calm, firm approach

Two weeks after a client has been admitted to the mental health hospital, the client's depression begins to lift. The nurse encourages involvement with unit activities, primarily because this type of activity: 1 Supports self-confidence 2 Provides for group interaction 3 Limits opportunities for suicide 4 Allows verbalization of repressed feelings of hostility

2 Group interaction provides a sense of belonging and fosters the assumption of responsibility. The group is not the best arena for the expression of repressed hostility. Support of self-confidence and limitation of opportunities for suicide are not ensured by group interaction.

A depressed client has been prescribed a tricyclic antidepressant. How long should the nurse inform the client that it will take before the client notices a significant change in the depression? 1 4 to 6 days 2 2 to 4 weeks 3 5 to 6 weeks 4 12 to 16 hours

2 It takes 2 to 4 weeks for the tricyclic antidepressant to reach a therapeutic blood level. Four to 6 days and 12 to 16 hours are both too short of time spans for a therapeutic blood level of the drug to be achieved. Improvement in depression should be demonstrated earlier than 5 to 6 weeks.

A nurse is caring for a client who is experiencing a major depression. What feeling should the nurse anticipate that the client will likely have difficulty expressing? 1 Need for comforting 2 Anger toward others 3 Remorse for past behaviors 4 Feelings of low self-esteem

2 The client is dependent, and such individuals can never get enough attention to meet their dependent needs. This unfulfilled need causes anger, which the client has problems expressing for fear of losing the people on whom the client is dependent. The client is expressing the need for comfort. The client is able to express remorse and guilt. The client is able to express feelings of low self-esteem.

A client with depression has not responded to a tricyclic antidepressant and outpatient electroconvulsive therapy (ECT). The health care provider prescribes selegiline (Eldepryl), and the nurse teaches the client about food to be avoided while taking this medication. Which foods identified by the client allow the nurse to conclude that the instructions have been understood? Select all that apply. 1 Fresh fish 2 Aged cheese 3 Fried chicken 4 Chocolate drinks 5 Leafy vegetables

2 & 4 Foods containing tyramine can cause hypertensive crisis and should be eliminated from the diet. These foods include pickled herring, beer, wine, chicken livers, aged or natural cheese, caffeine, cola, licorice, avocados, bananas, and bologna. Chocolate in moderation is safe for some patients, but it does contain caffeine. Overripe fruits and caffeine have high levels of tyramine, which can cause dangerous hypertension in clients taking monoamine oxidase inhibitors (MAOIs). Also, large amounts of caffeine can increase blood pressure and should be avoided. There is no need to limit the intake of fish, chicken, or leafy vegetables while taking an MAOI.

Which statement from a depressed patient might recede a suicide attempt? 1. I want to be the best I can be 2. I have decided to solve all my problems 3. I have the most horrendous family 4. I will try and work with the staff

2. I have decided to solve all my problems

A client is admitted to the hospital with a diagnosis of depression. What clinical manifestations of depression does the nurse expect when assessing this client? 1 Flight of ideas 2 Suspicion of others 3 Psychomotor retardation 4 Intrusive social behaviors

3 Both thought and motor activity, which require physical and psychic energy, are commonly slowed when someone is depressed. Flight of ideas is associated with manic behavior because it requires psychic energy. Suspicion is associated with paranoid ideation and is less common with depression. Intrusive social behaviors are associated with manic behavior.

A client with a diagnosis of bipolar I disorder with rapid cycling is readmitted 4 months after discharge. On the first day on the unit the client continually interrupts the nurse and is increasingly talkative and loud. What is the most therapeutic response by the nurse? 1 "You seem to have a need to interrupt me." 2 "How's your relationship with your spouse?" 3 "Do you realize that you're talking loud and fast?" 4 "Tell me about the medication you've been taking."

4 Antidepressants can induce rapidly cycling behavior, or the client may not be taking medications as prescribed; asking the client to talk about the medication will elicit information in a nonchallenging, nonthreatening manner. Observing that the client seems to have a need to interrupt the nurse is challenging and is not focused on assessing the problem. The question "How is your relationship with your spouse?" is not focused on the behavior being manifested. Asking the client whether he realizes that he is speaking loudly and quickly does little to promote discussion.

A client with major depression is admitted to the hospital. What is the most therapeutic initial nursing intervention? 1 Introducing the client to one other client 2 Requiring participation in therapy sessions 3 Encouraging interaction with others in small groups 4 Conveying an attitude of concern that is not intrusive

4 Conveying concern without being intrusive will allow the client to control the pace of development of the nurse-client relationship. Depressed clients are unable to move into relationships with other clients or group situations. It is too early for therapy sessions; the first thing that must be established is a trusting nurse-client relationship.

When caring for a client with major depression, nurses usually have the most difficulty dealing with the: 1 Client's lack of energy 2 Negative nonverbal responses 3 Client's psychomotor retardation 4 Pervasive quality of the depression

4 Depression is "contagious"; it affects the nurse as well as the client. The client's lack of energy should not make nursing care difficult. These clients usually do not offer negative responses; they offer no response.

A patient suffering from Bipolar I Disorder is admitted in a manic episode to the Mental Health Inpatient Unit. What should be included in your assessment in addition to suicide?

Amount of sleep, nutritional status, history of aggression, a/v hallucinations, etc...

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Block the reuptake of serotonin and norepinephrine; often used as 2nd line treatment if pt does not respond to SSRIs; similar side effect profile as SSRIs; need to monitor BP and HR

Norepinephrine Dopamine Reuptake Inhibitor (NDRI)

Bupropion (Wellbutrin) Blocks the reuptake of norepinephrine and dopamine; Stimulant action may reduce appetite; May increase sexual desire; Used as an aid to quit smoking Contraindicated in pt with seizure and eating disorders

Client Needs: Health Promotion and Maintenance 25. 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: a. discuss with the health care provider the need to increase the dose. b. reassure the patient that the medication will be effective soon. c. explain the time lag before antidepressants relieve symptoms. d. critically assess the patient for symptoms of improvement.

C 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266 (Table 14-6) | Page 268 (Box 14-3) TOP: Nursing Process: Implementation

Which nursing diagnosis would be least useful for a depressed client who shows psychomotor retardation? A. Constipation B. Death anxiety C. Activity intolerance D. Self-care deficit: bathing/hygiene

Death anxiety

Tricyclic Antidepressants (TCA's)

ELAVIL-amitriptyline TORFRANIL-imipramine ANAFRANIL-clomipramine AVENTYL-nortriplyline LUDIOMIL-amoxapine

Predisposing Factors

Family hx of depression Having experienced recent negative stressors Having childhood experiences in a negative home environment Lacking a social support system Having significant physical disease

affect

Feeling, mood, or emotional tone; objective

What is important to remember of Lamictal?

If you see a rash, STOP THE MEDS!

anhedonia

Inability or decreased ability to experience pleasure, joy, intimacy, and closeness.

What are some key points with mood disorders in the elderly?

Older adults (65 years and older) with an MDD or a DD are often -underdiagnosed or misdiagnosed -Diagnosed with types of dementia

Melancholic features

This outdated term indicates a severe form of endogenous depression (not attributable to environmental stressors) characterized by severe apathy, weight loss, profound guilt, symptoms that are worse in the morning, early morning awakening, and often suicidal ideation.

psychomotor retardation

a generalized slowing of physical and mental reactions; seen frequently in depression, intoxications, and other conditions

transcranial magnetic stimulation (TMS)

a technique that permits scientists to temporarily enhance or depress activity in a specific area of the brain

TCA SIDE EFFECTS

cardiovascular -can be fatal in overdose; do not give to suicidal

apathy

indifference

affect

outwardly bodily expression of emotions

flight of ideas

shifting from one idea to another quickly

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." The reply by the nurse that clarifies prevalence is A. "That is a good observation. Depression does mostly strike people older than 50 years." B. "Depression is seen in people of all ages, from childhood to old age." C. "Depression is most often seen among the middle adult age group." D. "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."

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." The reply by the nurse that clarifies the prevalence of this disease is "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.

Sasha is a 38-year-old patient admitted with major depression. Which of the following statements Sasha makes alerts you to a common accompaniment to depression? "I still pray and read my Bible every day." "My mother wants to move in with me, but I want to independent." "I still feel bad about my sister dying of cancer. I should have done more for her!" "I've heard others say that depression is a sign of weakness."

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

4 other antidepressant drugs that are not used as commonly

-bupropion (Wellbutrin) -Zyban -trazodone -MAOIs

What symptoms would you expect to find in someone suffering from major depression?

-depressed mood and anhedonia -substantial pain and suffering: psychologic, social, and occupational disability -history of one or more depressive episodes -possible psychotic features

Dysthymic Disorder (dysthymia)

-early and insidious onset -chronic depressive syndrome (chronic sadness) -present most of the day, more days than not, for at least 2 years and one year for children

Bipolar II disorder

-hypomanic episode(s) alternating with major depression -not accompanied by psychosis

serotonin syndrome

-idiosyncratic medication reaction due to accumulation of serotonin -rare and life-threatening -risk is greatest when SSRI is administered in combination with monoamine oxidase inhibitor (MAOI)

Bipolar spectrum disorders are characterized by what two opposite poles?

-mania (euphoria) and depression

What are MAOIs? What do they do?

-monoamine oxidase inhibitors -prevent the breakdown of norepinephrine, serotonin, and dopamine

6 subtypes observed in major depressive disorder

-psychotic features -melancholic features -atypical features -catatonic features -postpartum onset -seasonal affective disorder

toxic effects of lithium

-tremor, ataxia, confusion, convulsions, and N/V

anticonvulsant drugs

-valproate (depakote/depakene) -carbamazepine (Tegretol) -lamotrogine (Lamictal)

The nurse is reviewing orders given for a patient with depression. Which order should the nurse question? 1. A low starting dose of a tricyclic antidepressant 2. An SSRI given initially with an MAOI 3. Electroconvulsive therapy to treat suicidal thoughts 4. Elavil to address the patient's agitation

An SSRI given initially with an MAOI

Monoamine Oxidase Inhibitors (MAOIs)

Efficacy similar to other antidepressants, but dietary restrictions and potential drug interactions make this drug less desirable Contraindicated in people taking other antidepressants Tyramine-rich food could bring about a hypertensive crisis

psychomotor agitation

Excessive motor and cognitive activity

hypersomnia

Excessive sleeping

Select the nursing diagnosis least likely to be chosen after analysis of data pertinent to a client with postpartum depression. A. Impaired parenting B. Ineffective role performance C. Health-seeking behaviors D. Risk for impaired parent/infant/child attachment

Health-seeking behaviors

Select the nursing diagnosis least likely to be chosen after analysis of data pertinent to a client with post-partum depression. Impaired parenting Ineffective role performance Health-seeking behaviors Risk for impaired parent/infant/child attachment

Health-seeking behaviors A client with severe depression of any etiology will not have the mental or physical energy to engage in health-seeking behaviors. Further, her negative view of self and the world would preclude such thinking.

What are the 2 most common psychiatric presentations? Why?

Mixed anxiety and depression because the 2 areas of the brain having to do with these systems are closely related

Postpartum onset.

Indicates onset within 4 weeks after childbirth. It is common for psychotic features to accompany this depression. Severe ruminations or delusional thoughts about the infant signify increased risk of harm to the infant.

Seasonal features (seasonal affective disorder, [SAD]).

Indicates that episodes mostly begin in fall or winter and remit in spring. These patients have reduced cerebral metabolic activity. SAD is characterized by anergia, hypersomnia, overeating, weight gain, and a craving for carbohydrates; it responds to light therapy

Catatonic features

Marked by nonresponsiveness, extreme psychomotor retardation (may seem paralyzed), withdrawal, and negativity.

Depression Nursing Diagnosis

Risk for suicide Hopelessness Ineffective coping Social isolation Spiritual distress Self care deficit

Self Assessment

Nurses can experience feelings of frustration, hopelessness, and annoyance. They can alter these responses by: Recognizing any unrealistic expectations they have of themselves or the client Identify feelings they are experiencing that originate with the client Understanding the part that neurotransmitters play in the client with depressed mood.

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? A. Onset of action is from 1 to 6 weeks. B. They tend to be more effective for men. C. They may cause recent memory impairment. D. They often cause the client to have diurnal variation.

Onset of action is from 1 to 6 weeks.

SSRI meds

PROZAC-fluoxetine ZOLOFT-sertraline PAXIL-paroxetine CELEXA-citalopram LUVOX-fluvoxamine LEXAPRO-escialopram

The nurse is caring for a patient who exhibits disorganized thinking and delusions. The patient repeatedly states, "I hear voices of aliens trying to contact me." The nurse should recognize this presentation as which type of major depressive disorder (MDD)? 1. Catatonic 2. Atypical 3. Melancholic 4. Psychotic

Psychotic

Individuals with depression are always evaluated for what?

RISK OF SUICIDE

The nurse is planning care for a patient with depression who will be discharged to home soon. What aspect of teaching should be the priority on the nurse's discharge plan of care? 1. Pharmacological teaching 2. Safety risk 3. Awareness of symptoms increasing depression 4. The need for interpersonal contact

Safety risk

Sasha has been having angry outbursts with staff and peers on the unit. You are talking with Sasha on her third day of admission. You ask whether she is having any thoughts of suicide. Sasha becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" Your response is based on the knowledge that: Sasha is getting better because she is able to be assertive. Sasha may be at high risk for self-harm. Sasha is probably experiencing transference. Sasha may be angry at someone else and projecting that anger to staff.

Sasha may be at high risk for self-harm. Overt hostility is highly correlated with suicide; therefore the patient may be considered high risk, and appropriate precautions should be taken. The other responses are incorrect with no evidence to support them.

MOOD stabilizers

TEGRETOL-carbamazepine DEPAKOTE-valproic acid NEUROTINE-gabapentin LAMICTAL-topiramate TRILEPTAL-oxcarbazepine LITHIUM-(Eskalith, lithobid)

Antipsychotic drugs

THORAZINE-chlorpromazine HALDOL-haloperidol PROLIXIN-fluphenazine

Major depression disorder

serotonin and norepinepherine decreased levels > 8 weeks

Unipolar depression

sleep disturbances, insomnia diminished eating depression may be agitated later in life

which responses of a child to a father's untimely death represent an early stage of normal grieving? select all that apply a. The child lies in bed, banging his head against the mattress, shouting, "No, no, no!" b. The child refuses to go to school 2 weeks after his father's funeral, claiming "aches and pains all over my body." c. the child begins to obsessively attend to his game card collection and spends hours sorting and ordering cards for the first month after his father's death. d. the child repeatedly comes home from school and reports "seeing Dad" around a corner, but then "just disappears."

a, b, c, d all the answers are correct

SSRI SE

agitation, restlessness, 1st 1-2 weeks serotonin syndrome-agitation, diarrhea, fast/irregualr heartbeat, loss of coordination, hallucinations, over reactive reflexes, tremor, confusion LOW TO NO FATALITY WITH OVERDOSE

manic episode

an elevated expanisve or irritable mood accompanies by hyperactivity, grandiosity, and loss of reality

Dysthymia cannot be diagnosed unless it has existed for A. at least 3 months. B. at least 6 months. C. at least 1 year. D. at least 2 years.

at least 2 years.

which statement indicates that a patient has successfully mourned a loss in his or her life? a. she was so strong after her husband died. She never cried the whole time. She kept a stiff upper lip. b. she was a wreck when her sister died. She cried and cried. It took her about a year before she resumed her usual activities with any zest. c. you know, he still talks about his mother as if she were alive today, and she's been dead for 4 years. d. He never talked about his wife after she died. He just picked up and went on life's way.

b. she was a wreck for about a year

hypo-mania

change in mood must be evident for at least 4 days lasting for 2 years in adults and 1 year in children

dysthymia

chronic low level depression

cyclothymia

chronic mood disorder of a at least 2 year hypomania. milder form of bipolar disorder

hypomanic episode

clients may appear happy, agreeable, humorous, and agreeable: not sever enough to cause significant impairment

What type of medical problems put people at a higher risk for depression?

co-occurring CHRONIC medical problems (hypertension, backache, deiabetes, heart problems, arthritis, etc)

After having a mastectomy, a patient shows no emotion, asks no questions and smiles almost continually. The nursing priority is to focus on: a. identification of the patient's support system b. a knowledge deficit pertaining to her illness c. referral for the patient to see a psychiatrist d. the meaning of the mastectomy to the patient

d. the meaning of the mastectomy

a patient tells the nurse that his wife of 50 years died unexpectedly 6 weeks ago. The best response from the nurse would be a. It must be comforting to know you had a wonderful marriage b. It often takes 6 weeks to get over a loss such as yours. c. certain medications might be very helpful for you at this time d. this must be a difficult time for you now.

d. this must be difficult time

nursing interventions for serotonin syndroms

discontinue meds and notify the prescribing authority

A client who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The client mentions she will take the medication along with the St. John's wort she uses daily. The nurse should A. agree that taking the drugs at the same time will help her remember them daily. B. caution the client to drink several glasses of water daily. C. suggest that the client also use a sun lamp daily. D. explain the high possibility of an adverse reaction.

explain the high possibility of an adverse reaction.

In your assessment of a patient who is severely depressed and just started on antidepressants, what would be behavior that would concern you and require further assessment?

sudden change in mood or behavior

Why are TCAs not usually given to suicidal patients?

overdose can cause severe cardiotoxicity and neurotoxicity, and is a significant cause of fatal drug poisoning

mood disorders

psychological disorders characterized by emotional extremes

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with A. senile dementia. B. hypertensive crisis. C. psychomotor agitation. D. central serotonin syndrome.

psychomotor agitation.

SSRI (select serotonin re-uptake inhibitors)

reason for use: depression blocks uptake of serotonin to increase serotonin at synapse

A nurse caring for a nearly mute depressed client wishes to show acceptance of the client. An intervention that would meet this objective would be to say A. "I will be spending time with you each day to try to improve your mood." B. "I would like to sit with you for 15 minutes now and again this afternoon." C. "Each day we will spend time together to talk about things that are bothering you." D. "It is important for you to share your thoughts with someone who can help you evaluate whether your thinking is realistic."

"I would like to sit with you for 15 minutes now and again this afternoon."

What statement about the comorbidity of depression is accurate? A. Depression most often exists in an individual as a single entity. B. Depression is commonly seen among individuals with medical disorders. C. Substance abuse and depression are seldom seen as comorbid disorders. D. Depression may coexist with other disorders but is rarely seen with schizophrenia.

Depression is commonly seen among individuals with medical disorders.

A positive characteristic that assists the nurse in the care of the manic patient is 1. flight of ideas 2. racing thoughts 3. taunting behavior 4. distractibility

4. Distratibility

anergia

lack of energy; passivity

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 begin to attack this cognitive distortion by suggesting, "Let's look at what you just said, that you can 'never do anything right.'" querying, "Tell me what things you think you are not able to do correctly." asking, "Is this part of the reason you think no one likes you?" saying, "That is the most unrealistic thing I have ever heard."

suggesting, "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.

The major reason for hospitalization for depressed patients is: inability to go to work. suicidal ideation. loss of appetite. psychomotor agitation.

suicidal ideation. Suicidal thoughts are a major reason for hospitalization for patients with major depression. It is imperative to intervene with such patients to keep them safe from self-harm. The other options describe symptoms of major depression but aren't by themselves the major reason for hospitalization.

kindling

the creation of electrostress in the brain from stress that results in alteration of neural functioning

learned helplessness theory

the view that clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation.

Learned helplessness

this has been used to explain the development of depression in certain social groups, such as the aged, people in ghettos, and women.

A depressed client tells the nurse he is in the 'acute phase' of his treatment for depression. The nurse recognizes that the client has been in treatment: A. for more than 4 months B. that is directed toward relapse prevention C. that focuses on prevention of future depression D. to reduce depressive symptoms

to reduce depressive symptoms

tricyclic antidepressants (TCAs)

used to treat depression/anxiety, moderate anticholinergic side effects; can be lethal in overdose

MDD Signs and Symptoms

5 or more s/s must also be present one of which must be either a depressed mood or loss of interest in previously enjoyed activities At least 4 or more s/s which include: changes in appetite or weight, sleep disturbances, fatigue or loss of energy, feelings of worthlessness or guilt, difficulty concentrating, thinking, or making decisions, or recurrent thoughts of death or suicide. Additional s/s may be: bodily aches and pains, irritability, or crankiness rather than sadness, social withdrawal, and neglect of activities that previously brought pleasure. Many times begins in childhood

Client Needs: Psychosocial Integrity 2. 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: a. verbalize realistic positive characteristics about self by (date). b. agree to take an antidepressant medication regularly by (date). c. initiate social interaction with another person daily by (date). d. identify two personal behaviors that alienate others by (date).

A 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274 TOP: Nursing Process: Outcomes Identification

Client Needs: Physiological Integrity 19. Which documentation for a patient diagnosed with major depression indicates the treatment plan was effective? a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. b. Slept 10 hours uninterrupted. Attended craft group; stated "project was a failure, just like me." c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, "I feel tired all the time."

A 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. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274-275 TOP: Nursing Process: Evaluation

Depression

A state wherein the person experiences profound sadness.

A depressed client is noted to pace most of the time, pull at her clothes, and wring her hands. These behaviors are consistent with senile dementia. hypertensive crisis. psychomotor agitation. central serotonin syndrome.

psychomotor agitation. These behaviors describe the psychomotor agitation sometimes seen in clients with the agitated type of depression.

Client Needs: Physiological Integrity 10. 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? a. "I really doubt that one person can be blamed for all the bad things that happen." b. "Let's look at one bad thing that happened to see if another explanation exists." c. "You are being extremely hard on yourself. Try to have a positive focus." d. "Are you saying that you don't have any good things happen?"

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-4) TOP: Nursing Process: Implementation

A client has a severe sleep pattern disturbance and psychomotor retardation. The nurse has developed a plan for him to spend 20 minutes in the gym at 1 PM. The hour immediately after the exercise period should be scheduled for A. rest. B. group therapy. C. individual therapy. D. occupational therapy.

rest.

Client Needs: Psychosocial Integrity 7. 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: a. dysthymia. c. euphoria. b. anhedonia. d. anergia.

B 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." PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 250 | Page 264 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include: a. distracting the patient from self-absorption. b. careful unobtrusive observation around the clock. c. allowing the patient to spend long periods alone in meditation. d. opportunities to assume a leadership role in the therapeutic milieu.

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-3) | Page 256 (Case Study and Nursing Care Plan 14-1) TOP: Nursing Process: Planning

Client Needs: Physiological Integrity 14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment? a. Nutrition and hydration b. Supporting physiological stability c. Reducing disorientation and confusion d. Assisting the patient to identify and test negative thoughts

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 271-272 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 8. 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: a. limit the patient's activities to those that can be performed in a sitting position. b. withhold the drug, force oral fluids, and notify the health care provider. c. teach the patient strategies to manage postural hypotension. d. update the patient's mental status examination.

C 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266-267 (Table 14-6) | Page 269 (Box 14-4) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 27. 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. a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities. b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet. c. Temporary memory impairments and confusion may occur with electroconvulsive therapy. d. The patient needs time to readjust to a pressured work schedule.

C 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 271-272 TOP: Nursing Process: Implementation

Client Needs: Physiological Integrity 15. 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: a. monitors sodium intake and weight daily. b. wears support stockings and elevates the legs when sitting. c. can identify foods with high selenium content that should be avoided. d. confers with a pharmacist when selecting over-the-counter medications.

D 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266-267 (Table 14-6) | Page 268-269 (Table 14-7) TOP: Nursing Process: Evaluation

Which nursing diagnosis would be least useful for a depressed client who shows psychomotor retardation? Constipation Death anxiety Activity intolerance Self-care deficit: bathing/hygiene

Death anxiety A client with psychomotor retardation has vegetative signs of depression and is often constipated, too tired to engage in activities, and lacks the energy to attend to personal hygiene. Depressed clients usually do not have death anxiety. They are more likely to welcome the idea of dying.

selective serotonin reuptake inhibitors (SSRIs)

selectively inhibits serotonin reuptake and results in potentiation of serotonergic neurotransmissions (Luvox, Paxilo, Prozac, Zoloft)

Assessment of thought processes of a client with depression is most likely to reveal A. good memory and concentration. B. delusions of persecution. C. self-deprecatory ideation. D. sexual preoccupation.

self-deprecatory ideation.

Mood Swings

They are a normal part of everyone's life. There are days when we feel up and days we feel down. That is normal. We get into trouble when: The mood is down for several days The longer we stay down the more likely it is depression Usually depression is associated with a significant loss.

light therapy

Treats seasonal affective disorder (SAD); scientifically proven to be effective, exposure to daily doses of intense light. Increases activity in the adrenal gland and the superchiasmatic nucleus.

Assessment of the thought processes of a client diagnosed with depression is most likely to reveal good memory and concentration. delusions of persecution. self-deprecatory ideation. sexual preoccupation.

self-deprecatory ideation. Depressed clients never feel good about themselves. They have a negative, self-deprecating view of the world.

It is likely that a client with seasonal affective disorder will begin to feel better in the A. fall. B. winter. C. spring. D. summer.

spring.

A depressed client tells the nurse "There is no sense in trying. I am never able to do anything right!" The nurse can best begin to attack this cognitive distortion by A. suggesting "Let's look at what you just said, that you can 'never do anything right.'" B. querying "Tell me what things you think you are not able to do correctly." C. asking "Is this part of the reason you think no one likes you?" D. saying "That is the most unrealistic thing I have ever heard."

suggesting "Let's look at what you just said, that you can 'never do anything right.'"

A client with severe depression has been regulated on a monamine oxidase inhibitor because trials of other antidepressants proved unsuccessful. She has a pass to go out to lunch with her husband. Given a choice of the following entrees, which can she safely eat? A. avocado salad plate. B. fruit and cottage cheese plate. C. kielbasa and sauerkraut. D. liver and bacon plate.

fruit and cottage cheese plate.

bipolar depression depression

hypersomnia-excessive tiredness changes in appitite-binge eating, carbohydrate craving-with loss of appetite

major long term effects of lithium

hypothyroidism and kidney impairment

Grief

is the emotional reaction that follows the loss of a love object.

Bereavement

is the expected reactions of grief and sadness upon learning of the loss of a loved one.

A depressed client tells the nurse "There is no sense in trying. I am never able do anything right!" The nurse can identify this cognitive distortion as an example of A. self-blame. B. catatonia. C. learned helplessness. D. discounting positive attributes.

learned helplessness.

Mood Stabilizer for Bipolar Disorders

lithium -first line agent for bipolar disorder

anhedonia

loss of interest and pleasure in activities

Beck suggests that the etiology of depression is related to A. sleep abnormalities. B. serotonin circuit dysfunction. C. negative processing of information. D. a belief that one has no control over outcomes.

negative processing of information.

What are the 2 major neurotransmitters associated with depression and mania?

norepinephrine and serotonin

When the clinician mentions that a client has anhedonia, the nurse can expect that the client A. has poor retention of recent events. B. has weight loss of 10 lb or more from anorexia. C. obtains no pleasure from previously enjoyed activities. D. has difficulty with tasks requiring fine motor skills.

obtains no pleasure from previously enjoyed activities.

Bipolar disorders type 1

one or more manic episodes hx of depressive disorder hyperverbal, animated, grandeous, belief they have abilities they don't really have

A depressed client tells the nurse he is in the "acute phase" of his treatment for depression. The nurse recognizes that the client has been in treatment for more than 4 months. that is directed toward relapse prevention. that focuses on prevention of future depression. to reduce depressive symptoms.

to reduce depressive symptoms. The acute phase of depression therapy (6-12 weeks) is directed toward the reduction of symptoms and restoration of psychosocial and work function and may require some hospitalization.

vagus nerve stimulation (VNS)

treatment in which the vagus nerve-the part of the autonomic nervous system that carries information from the head, neck, thorax, and abdomen to several areas of the brain, including the hypothalamus and amygdala-is stimulated by a small electronic device much like a cardiac pacemaker, which is surgically implanted under a patient's skin in the left chest wall

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 A. wait quietly for the client to reply. B. prompt the client if the reply is slow. C. repeat the question if the client does not answer promptly. D. seek information from the client's significant others.

wait quietly for the client to reply.

The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client with severe depression. The most reliable evaluation of outcomes will be based on A. energy level. B. weekly weights. C. observed eating patterns. D. client statement of appetite.

weekly weights.

The nursing diagnosis Imbalanced nutrition: less than body requirements has been identified for a client diagnosed with severe depression. The most reliable evaluation of outcomes will be based on the client's energy level. weekly weights. observed eating patterns. statement of appetite.

weekly weights. The client's body weight is the most reliable and objective evaluation of success in treating this nursing diagnosis.

Physical (vegetative) symptoms

weight change-loss or gain sleep disturbance-loss or gain low energy and sex drive constipation psychomotor disturbances-agitation or retardation

Sasha is started on fluoxetine. Which statement by Sasha indicates that she understands the medication teaching you have provided? "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction." "I will not take any over-the-counter medication while on the fluoxetine." "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." "I will report increased thirst and urination to my provider."

"I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." This describes symptoms of serotonin syndrome, a life-threatening complication of SRRI medication. The other options are incorrect because the patient should be wearing sunscreen to avoid sunburn, may take over-the-counter medications if sanctioned by the provider, and would not have been educated to report increased thirst and urination as a side effect of fluoxetine.

When teaching parents about childhood depression the nurse should say that it: 1 May appear as acting-out behavior 2 Does not respond to conventional treatment 3 Looks almost identical to adult depression 4 Is short in duration and has an early resolution

1 Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may indicate an underlying depression. Adult and childhood depression may be manifested in different ways. Childhood depression is not necessarily short and requires treatment. Many conventional therapies for adults with depression, including medication, are effective for children with depression.

A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? 1 Outbursts of anger 2 Focused concentration 3 Preoccupation with delusions 4 Intense interpersonal relationships

1 Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.

A 25-year-old woman with the diagnosis of bipolar disorder, manic episode, is admitted to the psychiatric unit. A nurse on the unit reviews the admission information provided by the client's husband and assesses the client. In light of the information in the chart, what is an appropriate nursing intervention? 1 Assigning the client to a private room 2 Suggesting that the client play cards with several other clients 3 Encouraging the development of insight through introspection 4 Having the client sit at the communal dining table during meals

1 During the acute phase of mania, care should be focused on maintaining the safety of the client and others and decreasing the client's energy expenditure. Hypersexuality is often associated with the manic episode of bipolar disorder. Obtaining sexual pleasure by exposing the genitals (exhibitionism) is a paraphilia. A private room protects the other clients and provides privacy for the client. The client is too hyperactive to engage in group activities, and hypersexual behavior may precipitate anxiety in the other clients. Also, manic clients can be overly competitive, which may disturb the other clients. Activities at this time should be solitary or one-on-one with the nurse or nursing assistant. Manic clients have flight of ideas (rapid racing thoughts) and are easily distracted. Introspection and the development of insight cannot occur during this phase of the illness. The hyperactive client will not have the self-control to sit long enough to eat a meal. The nurse should provide finger foods and other portable foods (e.g., sandwich, fruit, milkshake) and encourage the intake of food with short declarative statements that direct the client to eat (e.g., "Finish your sandwich," "Eat this banana").

A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Select all that apply. 1 Insomnia 2 Irritability 3 Excessive eating 4 Decreased libido 5 Financial irresponsibility

1,2,5 During a manic episode there is a decreased need for sleep and clients do not feel tired. During a manic episode the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode there is a decrease in appetite. The client's increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode. During a manic episode impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences.

A client is admitted with the diagnosis of borderline personality disorder/possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client? 1 Degree of anger 2 Potential for suicide 3 Level of intelligence 4 Ability to test reality

2 Depressed clients may use suicide as the ultimate escape from feelings; ensuring safety by protecting the client from self-harm is the priority. Although degree of anger is important, it is not the priority. Assessment of the level of intelligence is unnecessary; clients with a diagnosis of borderline personality disorder are usually of average intelligence. Clients with a diagnosis of borderline personality disorder are more concerned with satisfying their needs than testing reality; they are more concerned about themselves than others or the environment.

Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. The most important intervention for the client who is given a PRN medication and confined to involuntary seclusion is to: 1 Continue intensive nursing interactions. 2 Evaluate the client's progress toward self-control. 3 Determine whether any staff member has been injured. 4 Observe the client for side effects of the medication given to the client.

2 For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.

When used in combination with certain foods and drugs, monoamine oxidase inhibitors (MAOIs) can cause serious side effects. Which condition could occur in clients treated with MAOIs for depression? 1 A serious drop in blood pressure 2 A serious increase in blood pressure 3 A significant increase in liver enzymes 4 A significant increase in cholesterol levels

2 MAOIs, when taken with foods high in tyramine (e.g., pickled foods, beer, wine, aged cheeses) and drugs such as antidepressants, certain pain medications, and decongestants, can cause a life-threatening increase in blood pressure. For this reason they are seldom used to treat symptoms of depression. MAOIs do not increase liver enzymes or cholesterol levels.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1 Dementia 2 Multiple losses 3 Declines in health 4 A milestone birthday 5 An injury requiring hospitalization

2 & 3 Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

A client has been found to have bipolar disorder and is being prescribed lithium carbonate (Lithium). In light of the information shown, the nurse provides teaching to the client. Select all that apply. TSH (10) Sodium (132) 1 Lithium can affect WBC production and therefore increases her risk for infection. 2 Her current thyroid function will require frequent assessments while she takes lithium. 3 Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level. 4 Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy. 5 The current hemoglobin and hematocrit call for regular monitoring is needed once the lithium level is stabilized.

2,3 Lithium carbonate therapy can negatively affect thyroid function; the client's current TSH is at the high normal level and so frequent checks are appropriate. Low serum sodium levels would result in the kidneys' reabsorbing the lithium; this situation would lead to lithium toxicity. The health care provider must first be notified of the lab result. Lithium is not known to have a negative effect on WBC, platelet, or RBC production. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

A nurse is caring for a client with bipolar I disorder. What should the plan of care for this client include? Select all that apply. 1 Touching the client to provide reassurance 2 Providing a structured environment for the client 3 Ensuring that the client's nutritional needs are met 4 Engaging the client in conversation about current affairs 5 Designing activities that require the client to maintain contact with reality

2,3 Structure tends to decrease agitation and anxiety and to increase the client's feelings of security. Whether the individual is experiencing mania or depression, nutritional needs must be met. The hyperactivity associated with mania interferes with the ability to sit still long enough to eat; hyperactivity requires an increase in the intake of calories for the energy expended. Touching can be threatening for many clients and should not be used indiscriminately. Conversations should be kept simple. The client with a bipolar disorder, either depressed or manic phase, may have difficulty following involved conversations about current affairs. Clients with bipolar disorders are in contact with reality, so designing activities that require the client to maintain such contact will serve little purpose.

A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis? 1 Loss of faith in God 2 Visual hallucinations 3 Decreased social interaction 4 Ambivalent feelings about the future

3 Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Depressed clients are commonly negative and pessimistic, especially regarding their future. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders.

A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? 1 Rigidity and a narrowing of perception 2 Alternating episodes of fatigue and high energy 3 Diminished pleasure in activities and alteration in appetite 4 Excessive socialization and interest in activities of daily living

3 Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug? 1 It must be given with milk and crackers to avoid hyperacidity and discomfort. 2 Eating cheese or pickled herring or drinking wine may cause a hypertensive crisis. 3 The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. 4 The blood level should be checked weekly for 3 months to monitor for an appropriate level.

3 Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with the monoamine oxidase inhibitors. Weekly blood level checks are not necessary with fluoxetine.

A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when he states that one major disadvantage of ECT is that: 1 The seizures may cause bone fractures. 2 Relief of symptoms requires many weeks of treatment. 3 Memory is impaired just before and after the treatment. 4 Loss of mental function occurs and continues for a long time.

3 Impaired memory is an expected side effect of the therapy. Succinylcholine (Anectine) prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.

A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time? 1 "I'm going to miss you; we've become good friends." 2 "I know that you're going to be all right when you go home." 3 "Call the contact number we gave you if you have an emergency." 4 "This is my phone number; call and let me know how you're doing."

3 Instructing the client to call the contact number that was provided in case of emergency demonstrates an understanding that the newly discharged client needs to have a support system. Clients need to feel that in a crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead to help the client become a functioning being again. "I know you're going to be all right when you go home" provides false reassurance; the nurse does not know this. "This is my phone number; call and let me know how you're doing" is unprofessional and blurs the roles of nurse and client.

The nurse notices that one of her clients, who has depression, is sitting by the window crying. The most appropriate response by the nurse is: 1 "It's OK. No need to cry or worry while you're here. We all feel down now and then." 2 "Please don't consider suicide. It really isn't an appropriate way out of your troubles." 3 "You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like." 4 "Why don't you go into the dayroom and join the card game going on? That'll take your mind off of your problems for a while."

3 The nurse is acknowledging that the client is feeling especially down and offering to be available for discussion or just to provide a presence. The response regarding suicide is judgmental and may discourage any effort by the client to initiate a discussion. Telling the client not to cry and suggesting a card game do not acknowledge the client's feelings and appear to trivialize the situation.

A client with the diagnosis of manic episode of bipolar disorder attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment? 1 Doing a needlepoint project 2 Joining a brief swimming competition 3 Walking around the facility with a nurse 4 Playing a board game with another client

3 Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client's anxiety. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.

A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display? 1 Elated affect related to reaction formation 2 Loose associations related to a thought disorder 3 Physical exhaustion related to decreased physical activity 4 Paucity of verbal expression related to slowed thought processes

4 As depression increases, thought processes become slower and verbal expression decreases due to lack of emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression. Physical exhaustion is associated with bipolar disorder, manic episode; decreased physical activity does not produce physical exhaustion.

A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity? 1 Find solitary pursuits that the client can enjoy. 2 Speak to the client about the importance of entering into activities. 3 Ask the health care provider to speak to the client about participating. 4 Invite another client to take part in a joint activity with the nurse and the client.

4 Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the health care provider to speak to the client about participating transfers the nurse's responsibility to the health care provider.

An effective mood-stabilizing drug used in clients with bipolar disorder in the acute treatment of mania and prevention of recurrent mania and depressive episodes is: 1 Doxepin (Sinequan) 2 Clozapine (Clozaril) 3 Amitriptyline (Elavil) 4 Lithium carbonate (Lithium)

4 Lithium carbonate is often the first choice of treatment, once primary acute mania has been diagnosed, to calm acute manic symptoms and relieve recurrent mania. Doxepin and amitriptyline are antidepressants used to treat depression but not mania. Clozaril is an antipsychotic medication used to control hallucinations and delusions in patients with psychosis but is not a first-line drug because of its side effects, which include seizures and significant weight gain.

A client is receiving carbamazepine (Tegretol) for the treatment of a manic episode of bipolar disorder. What should the nurse include when planning client teaching about this medication? Select all that apply. 1 "You have to eat a low-sodium diet every day." 2 "You'll have to take a diuretic with this medication." 3 "You'll have to take this medication for the rest of your life." 4 "You may want to suck on hard candy when you get a dry mouth." 5 "We'll need to test your blood often during the first few weeks of therapy."

4,5 Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. Carbamazepine can cause severe bone marrow depression in the early phase of therapy. Also, the drug level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required; nor is a diuretic. The client may or may not have to take the medication for life.

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1 Passivity 2 Dysphoria 3 Anhedonia 4 Grandiosity 5 Talkativeness 6 Distractibility

4,5,6 Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Dysphoria, a depressed, sad mood, is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.

Client Needs: Psychosocial Integrity 17. 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? a. Make observations. b. Ask the patient direct questions. c. Phrase questions to require yes or no answers. d. Frequently reassure the patient to reduce guilt feelings.

A 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 261-263 (Table 14-3) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 4. 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? a. Social skills training c. Desensitization techniques b. Relaxation training classes d. Use of complementary therapy

A 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. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 259 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient's symptoms be most acute? a. January c. June b. April d. September

A 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 271-272 TOP: Nursing Process: Assessment

dysthymic disorder (DD)

A chronically depressed mood that is present for more than 2 yrs in an adult or 1 yr in a child or adolescent. Affected persons describe themselves as being chronically "down in the dumps".

Client Needs: Psychosocial Integrity 3. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply. a. Offer laxatives if needed. b. Monitor food and fluid intake. c. Provide a quiet sleep environment. d. Eliminate all daily caffeine intake. e. Restrict intake of processed foods.

A, B, C 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. See relationship to audience response question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 257 | Page 260-261 (Table 14-2) | Page 264 (Table 14-5) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 2. 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. a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia

A, C, D, F 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 257-261 (Table 14-2) | Page 264 (Table 14-5) TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Psychosocial Integrity 4. 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. a. Vital signs b. Urinary frequency c. Psychomotor retardation d. Presence of abdominal pain and diarrhea e. Hyperactivity or feelings of restlessness

A, D, E 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 265-268 (Box 14-2) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 21. 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. a. Powerlessness c. Stress overload b. Risk for suicide d. Spiritual distress

B 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. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 255 | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 260 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Physiological Integrity 23. 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? a. Affect depressed; mood flat c. Affect labile; mood euphoric b. Affect flat; mood depressed d. Affect and mood are incongruent.

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 257-258 TOP: Nursing Process: Assessment

Client Needs: Health Promotion and Maintenance 28. 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: a. hypotensive shock. c. cardiac dysrhythmia. b. hypertensive crisis. d. cardiogenic shock.

B 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 266 (Table 14-6) | Page 268-269 | Page 270 (Table 14-8) TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 3. 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? a. "You look nice this morning." c. "I like the shirt you are wearing." b. "You're wearing a new shirt." d. "You must be feeling better today."

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 274 TOP: Nursing Process: Implementation

Client Needs: Physiological Integrity 13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve? a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee b. Mashed potatoes, ground beef patty, corn, green beans, apple pie c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 266-267 (Table 14?6) | Page 268-269 (Table 14-7) TOP: Nursing Process: Evaluation

Client Needs: Physiological Integrity 29. 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? a. "They will put me to sleep during the procedure so I won't know what is happening." b. "I might be a little dizzy or have a mild headache after each procedure." c. "I will be unable to care for my children for about 2 months." d. "I will avoid eating foods that contain tyramine."

B 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 271-272 TOP: Nursing Process: Evaluation

Client Needs: Safe, Effective Care Environment 6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using: a. psychoanalytic therapy. b. desensitization therapy. c. cognitive behavioral therapy. d. alternative and complementary therapies.

C 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 274 TOP: Nursing Process: Planning

Client Needs: Psychosocial Integrity 12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about: a. restricting sodium intake to 1 gram daily. b. minimizing exposure to bright sunlight. c. reporting increased suicidal thoughts. d. maintaining a tyramine-free diet.

C 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 268 (Box 14-3) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 18. 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: a. "Go to the nearest emergency department immediately." b. "Do not to be alarmed. Take two aspirin and drink plenty of fluids." c. "Take a dose of your antidepressant now and come to the clinic to see the health care provider." d. "Resume taking your antidepressants for 2 more weeks and then discontinue them again."

C 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-4) TOP: Nursing Process: Implementation

Client Needs: Physiological Integrity 16. 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? a. Powerlessness c. Situational low self-esteem b. Defensive coping d. Disturbed personal identity

C 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 250-251 | Page 256 (Case Study and Nursing Care Plan 14-1) | Page 259 TOP: Nursing Process: Diagnosis/Analysis

Client Needs: Physiological Integrity MULTIPLE RESPONSE 1. 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. a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation

C, D, E 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. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 257 | Page 261 TOP: Nursing Process: Planning

Client Needs: Physiological Integrity 9. 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? a. Dry mouth c. Nasal congestion b. Blurred vision d. Urinary retention

D 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. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Page 266-267 (Table 14-6) | Page 269 (Box 14-4) TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 22. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient? a. Tomato juice c. Hot tea b. Orange juice d. Milk

D Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 264 (Table 14-5) TOP: Nursing Process: Implementation

Client Needs: Physiological Integrity 26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient? a. Arms crossed c. Smiling inappropriately b. Staring at the nurse d. Eyes pointed downward

D Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 256 (Case Study and Nursing Care Plan 14-1) | Page 260 TOP: Nursing Process: Assessment

Client Needs: Psychosocial Integrity 11. 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: a. guilt and despair. c. interest and pleasure. b. over-involvement. d. ineffectiveness and frustration.

D 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. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 260-261 TOP: Nursing Process: Evaluation

Chapter 14: Depressive Disorders MULTIPLE CHOICE 1. 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? a. "Things will look brighter soon. Everyone feels down once in a while." b. "Our staff members care about you and want to try to help you get better." c. "It is difficult for others to care about you when you repeatedly say the same negative things." d. "I'll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you."

D 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 263 (Table 14-4) | Page 256 (Case Study and Nursing Care Plan 14-1) TOP: Nursing Process: Implementation

Client Needs: Psychosocial Integrity 24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will: a. bring up the issue at the community meeting. b. calmly tell the patient, "You must bathe daily." c. avoid forcing the issue in order to minimize stress. d. firmly and neutrally assist the patient with showering.

D 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. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 259 | Page 261 (Table 14-2) | Page 256 (Case Study/Nursing Care Plan 14-1) TOP: Nursing Process: Implementation

What statement about the comorbidity of depression is accurate? Depression most often exists in an individual as a single entity. Depression is commonly seen in individuals with medical disorders. Substance abuse and depression are seldom seen as comorbid disorders. Depression may coexist with other disorders but is rarely seen with schizophrenia.

Depression is commonly seen in individuals with medical disorders. Depression commonly accompanies medical disorders. The other options are false statements.

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? Onset of action is from 1 to 6 weeks. 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 6 weeks. People are accustomed to fast results from medication: thirty minutes for aspirin, 24 hours for antibiotics. Information is necessary to prevent discouragement and maintain compliance.

The nurse has developed a plan for a client with a severe sleep pattern disturbance to spend 20 minutes in the gym exercising each afternoon. Which intervention should be scheduled for upon returning to the unit? Rest Group therapy A protein-based snack Unstructured private time

Rest A depressed client usually has little energy. After even a short exercise period, the client may feel exhausted and need rest.

Sasha's roommate Kate was admitted with major depression and suicidal ideation with a plan to overdose. Kate is preparing for discharge and asks you, "Why did Dr. Travis give me a prescription for only 7 days of amitriptyline?" Your response is based on the knowledge that: amitriptyline (Elavil) is very expensive, so the patient may have to buy fewer at a time. Dr. Travis is going to see how Kate responds to the first week of medication to evaluate its effectiveness. Dr. Travis wants to see whether any minor side effects occur within the first week of administration. amitriptyline (Elavil) is lethal in overdose.

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

Dysthymia cannot be diagnosed unless it has existed for at least 3 months. at least 6 months. at least 1 year. at least 2 years.

at least 2 years. Dysthymia is a chronic condition that by definition has to have existed for longer than 2 years.

major depressive disorder (MDD)

experience substantial pain and suffering. at least one depressive episode. Lasts at least two weeks. Represents a change from previous functioning. Causes some impairment in social or occupationals functioning.

A client who has been assessed by the nurse as moderately depressed is given a prescription for daily doses of a selective serotonin reuptake inhibitor. The client mentions that she will take the medication along with the St. John's wort she uses daily. The nurse should agree that taking the drugs at the same time will help her remember them daily. 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.

A client prescribed a monamine oxidase inhibitor (MOA) has a pass to go out to lunch. Given a choice of the following entrees, the client can safely eat avocado salad plate. fruit and cottage cheese plate. kielbasa and sauerkraut. liver and onion sandwich.

fruit and cottage cheese plate. Fruit and cottage cheese do not contain tyramine. Avocados, fermented food such as sauerkraut, processed meat, and organ meat contain tyramine. Monoamine oxidase inhibitors inhibit the breakdown of tyramine, which can lead to high blood pressure, a hypertensive crisis, and eventually a cerebrovascular accident.

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

Beck's cognitive theory suggests that the etiology of depression is related to sleep abnormalities. serotonin circuit dysfunction. negative processing of information. a belief that one has no control over outcomes.

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

When the clinician mentions that a client has anhedonia, the nurse can expect that the client has poor retention of recent events. experienced a weight loss from anorexia. obtains no pleasure from previously enjoyed activities. has difficulty with tasks requiring fine motor skills.

obtains no pleasure from previously enjoyed activities. Anhedonia is the term for the lack of ability to experience pleasure.

DD Signs and Symptoms

poor appetite or overeating, insomnia or hypersomnia, fatigue, low self esteem, poor concentration, feelings of hopelessness. And often begins in childhood.