Question 1
Regular
A patient became severely depressed when the last of 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?
Correct!
Incorrect
The correct answer is: D
Rationale
I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon.
This response demonstrates a commitment to providing consistent, attentive support, which is crucial for someone experiencing severe depression. By offering specific times to check in, the nurse fosters a sense of connection and reliability, helping the patient feel valued and cared for during a challenging time.
A: Things will look brighter soon. Everyone feels down once in a while. This statement minimizes the patient’s feelings and lacks empathetic engagement, potentially further deepening their sense of isolation.
B: The staff here cares about you and wants to try to help you get better. While this conveys concern, it lacks personal connection and does not provide immediate emotional support or reassurance.
C: It is difficult for others to care about you when you repeatedly say negative things about yourself. This response shifts blame onto the patient, which can exacerbate feelings of worthlessness and discourage open communication.
Correct Answer: D
Rationale: I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon.
This response demonstrates a commitment to providing consistent, attentive support, which is crucial for someone experiencing severe depression. By offering specific times to check in, the nurse fosters a sense of connection and reliability, helping the patient feel valued and cared for during a challenging time.
A: Things will look brighter soon. Everyone feels down once in a while. This statement minimizes the patient’s feelings and lacks empathetic engagement, potentially further deepening their sense of isolation.
B: The staff here cares about you and wants to try to help you get better. While this conveys concern, it lacks personal connection and does not provide immediate emotional support or reassurance.
C: It is difficult for others to care about you when you repeatedly say negative things about yourself. This response shifts blame onto the patient, which can exacerbate feelings of worthlessness and discourage open communication.
Question 2
Regular
A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, 'No one cares about me anymore. I'm not worth anything.' Select an appropriate initial outcome.
Correct!
Incorrect
The correct answer is: A
Rationale
The patient will verbalize realistic positive characteristics about self by (date).
This outcome is appropriate as it directly addresses the patient's negative self-perception and aims to foster a more positive self-image, which is essential for overcoming depression and improving overall mental health.
B: The patient will consent to take antidepressant medication regularly by (date). Medication compliance is vital, but this outcome does not tackle the immediate emotional distress or self-worth issues the patient faces.
C: The patient will initiate social interaction with another person daily by (date). While social engagement is beneficial, the primary concern of self-worth and negative thoughts must be addressed before encouraging interactions with others.
D: The patient will identify two personal behaviors that alienate others by (date). Focusing on behaviors that push others away does not directly confront the patient's deep-seated feelings of worthlessness and depression, which need priority attention.
Correct Answer: A
Rationale: The patient will verbalize realistic positive characteristics about self by (date).
This outcome is appropriate as it directly addresses the patient's negative self-perception and aims to foster a more positive self-image, which is essential for overcoming depression and improving overall mental health.
B: The patient will consent to take antidepressant medication regularly by (date). Medication compliance is vital, but this outcome does not tackle the immediate emotional distress or self-worth issues the patient faces.
C: The patient will initiate social interaction with another person daily by (date). While social engagement is beneficial, the primary concern of self-worth and negative thoughts must be addressed before encouraging interactions with others.
D: The patient will identify two personal behaviors that alienate others by (date). Focusing on behaviors that push others away does not directly confront the patient's deep-seated feelings of worthlessness and depression, which need priority attention.
Question 3
Regular
A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?
Correct!
Incorrect
The correct answer is: B
Rationale
You are wearing a new shirt. This remark specifically acknowledges the patient's effort to present themselves well, reinforcing their choices and positively impacting their self-esteem, which is crucial in managing major depressive disorder.
A: You look nice this morning. While this is a compliment, it lacks specificity and does not directly acknowledge the patient’s choice, which is important for building self-esteem.
C: I like the shirt you're wearing. This statement expresses personal preference but does not highlight the patient's initiative to wear something new, which is essential for reinforcing positive self-image.
D: You must be feeling better today. This assumption could be misleading or invalidating; the patient may still be struggling despite their appearance, making this remark less supportive for their self-esteem.
Correct Answer: B
Rationale: You are wearing a new shirt. This remark specifically acknowledges the patient's effort to present themselves well, reinforcing their choices and positively impacting their self-esteem, which is crucial in managing major depressive disorder.
A: You look nice this morning. While this is a compliment, it lacks specificity and does not directly acknowledge the patient’s choice, which is important for building self-esteem.
C: I like the shirt you're wearing. This statement expresses personal preference but does not highlight the patient's initiative to wear something new, which is essential for reinforcing positive self-image.
D: You must be feeling better today. This assumption could be misleading or invalidating; the patient may still be struggling despite their appearance, making this remark less supportive for their self-esteem.
Question 4
Regular
An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Social skills training enhances interpersonal effectiveness, empowering the patient to engage actively in social situations. This intervention directly addresses passivity, promoting increased confidence and reducing depressive symptoms by fostering healthier relationships.
B: Relaxation training classes primarily focus on stress reduction and anxiety management, lacking direct emphasis on social interaction skills that are essential for overcoming passivity in this context.
C: Use of complementary therapy encompasses various alternative approaches, which may not specifically target the development of social skills necessary for addressing passivity that contributes to the patient’s depression.
D: Learning desensitization techniques aims at reducing anxiety responses but does not effectively address the broader issue of passivity and its role in the patient's major depressive disorder.
Correct Answer: A
Rationale: A: Social skills training enhances interpersonal effectiveness, empowering the patient to engage actively in social situations. This intervention directly addresses passivity, promoting increased confidence and reducing depressive symptoms by fostering healthier relationships.
B: Relaxation training classes primarily focus on stress reduction and anxiety management, lacking direct emphasis on social interaction skills that are essential for overcoming passivity in this context.
C: Use of complementary therapy encompasses various alternative approaches, which may not specifically target the development of social skills necessary for addressing passivity that contributes to the patient’s depression.
D: Learning desensitization techniques aims at reducing anxiety responses but does not effectively address the broader issue of passivity and its role in the patient's major depressive disorder.
Question 5
Regular
What is a priority nursing intervention for a patient diagnosed with major depressive disorder?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Carefully and inconspicuously observing the patient around the clock is essential for ensuring safety and identifying any potential risk of self-harm or suicidal thoughts, which are prevalent in major depressive disorder. Continuous observation allows for timely intervention and support, fostering a secure environment for the patient while they navigate their treatment journey.
A: Distracting the patient from self-absorption fails to address the underlying issues of depression and may hinder emotional processing critical for healing and recovery.
C: Allowing the patient to spend long periods alone in self-reflection can exacerbate feelings of isolation and hopelessness, potentially leading to a decline in mental health status.
D: Offering opportunities for the patient to assume a leadership role could overwhelm them, as individuals with major depressive disorder may struggle with self-esteem and motivation, leading to further distress.
Correct Answer: B
Rationale: B: Carefully and inconspicuously observing the patient around the clock is essential for ensuring safety and identifying any potential risk of self-harm or suicidal thoughts, which are prevalent in major depressive disorder. Continuous observation allows for timely intervention and support, fostering a secure environment for the patient while they navigate their treatment journey.
A: Distracting the patient from self-absorption fails to address the underlying issues of depression and may hinder emotional processing critical for healing and recovery.
C: Allowing the patient to spend long periods alone in self-reflection can exacerbate feelings of isolation and hopelessness, potentially leading to a decline in mental health status.
D: Offering opportunities for the patient to assume a leadership role could overwhelm them, as individuals with major depressive disorder may struggle with self-esteem and motivation, leading to further distress.
Question 6
Regular
When counseling patients diagnosed with major depressive disorder, how will an advanced practice nurse likely address the negative thought patterns?
Correct!
Incorrect
The correct answer is: C
Rationale
Cognitive behavioral therapy. This approach effectively helps patients identify and challenge negative thought patterns, replacing them with more positive and realistic perspectives, thus alleviating symptoms of major depressive disorder.
A: Psychoanalytic therapy. This method primarily explores unconscious thoughts and past experiences, which may not directly address the immediate negative thinking patterns prevalent in major depressive disorder.
B: Desensitization therapy. This technique focuses on reducing anxiety responses to specific stimuli, which does not specifically target the cognitive distortions commonly associated with major depressive disorder.
D: Alternative and complementary therapies. While these may offer supportive benefits, they lack the structured cognitive approach necessary for effectively modifying negative thought patterns in patients with major depressive disorder.
Correct Answer: C
Rationale: Cognitive behavioral therapy. This approach effectively helps patients identify and challenge negative thought patterns, replacing them with more positive and realistic perspectives, thus alleviating symptoms of major depressive disorder.
A: Psychoanalytic therapy. This method primarily explores unconscious thoughts and past experiences, which may not directly address the immediate negative thinking patterns prevalent in major depressive disorder.
B: Desensitization therapy. This technique focuses on reducing anxiety responses to specific stimuli, which does not specifically target the cognitive distortions commonly associated with major depressive disorder.
D: Alternative and complementary therapies. While these may offer supportive benefits, they lack the structured cognitive approach necessary for effectively modifying negative thought patterns in patients with major depressive disorder.
Question 7
Regular
A patient says to the nurse, 'My life does not have any happiness in it anymore. I once enjoyed holidays, but now they're just another day.' How would the nurse document the patient's statement?
Correct!
Incorrect
The correct answer is: B
Rationale
B: Anhedonia. The patient's expression of lost joy and enjoyment in activities previously cherished like holidays indicates a state of anhedonia, characterized by a diminished capacity to experience pleasure in life.
A: Vegetative. This term refers to a state of unresponsiveness or lack of awareness, which does not accurately reflect the patient's ability to articulate feelings of unhappiness and loss of enjoyment.
C: Euphoria. Euphoria signifies an intense state of happiness or excitement, contrasting sharply with the patient's report of pervasive unhappiness and absence of joy in their life.
D: Anergia. Anergia describes a lack of energy or motivation, which does not fully capture the patient's specific expression of losing the ability to feel pleasure from previously enjoyable activities.
Correct Answer: B
Rationale: B: Anhedonia. The patient's expression of lost joy and enjoyment in activities previously cherished like holidays indicates a state of anhedonia, characterized by a diminished capacity to experience pleasure in life.
A: Vegetative. This term refers to a state of unresponsiveness or lack of awareness, which does not accurately reflect the patient's ability to articulate feelings of unhappiness and loss of enjoyment.
C: Euphoria. Euphoria signifies an intense state of happiness or excitement, contrasting sharply with the patient's report of pervasive unhappiness and absence of joy in their life.
D: Anergia. Anergia describes a lack of energy or motivation, which does not fully capture the patient's specific expression of losing the ability to feel pleasure from previously enjoyable activities.
Question 8
Regular
A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. 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 should implement what intervention?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Explain how to manage postural hypotension and educate the patient that side effects go away after several weeks. This intervention addresses the patient's dizziness, providing essential education on managing side effects while reassuring them about potential improvements over time, which can encourage adherence to treatment.
B: Tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. This approach minimizes the patient's concerns and fails to validate their experience, potentially leading to non-compliance with medication.
C: Withhold the drug, force oral fluids, and notify the health care provider to examine the patient. This action may be excessive without first attempting to manage the side effect through education and support, potentially disrupting the treatment plan unnecessarily.
D: Teach the patient how to use pursed-lip breathing. While beneficial for respiratory issues or anxiety, this technique does not address the dizziness caused by postural hypotension related to the tricyclic antidepressant.
Correct Answer: A
Rationale: A: Explain how to manage postural hypotension and educate the patient that side effects go away after several weeks. This intervention addresses the patient's dizziness, providing essential education on managing side effects while reassuring them about potential improvements over time, which can encourage adherence to treatment.
B: Tell the patient that the side effects are a minor inconvenience compared with the feelings of depression. This approach minimizes the patient's concerns and fails to validate their experience, potentially leading to non-compliance with medication.
C: Withhold the drug, force oral fluids, and notify the health care provider to examine the patient. This action may be excessive without first attempting to manage the side effect through education and support, potentially disrupting the treatment plan unnecessarily.
D: Teach the patient how to use pursed-lip breathing. While beneficial for respiratory issues or anxiety, this technique does not address the dizziness caused by postural hypotension related to the tricyclic antidepressant.
Question 9
Regular
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?
Correct!
Incorrect
The correct answer is: D
Rationale
Urinary retention
Imipramine, a tricyclic antidepressant, can significantly affect bladder function, leading to urinary retention. This side effect poses serious risks, including urinary tract infections and bladder distension, necessitating immediate collaboration with the health care provider to manage the patient's safety effectively.
A: Dry mouth Commonly experienced with tricyclic antidepressants, dry mouth does not pose immediate health risks. It can be managed with hydration and oral care without necessitating urgent intervention.
B: Blurred vision While blurred vision can occur, it typically resolves without complications. This side effect is often manageable and does not usually indicate severe health concerns needing immediate escalation.
C: Nasal congestion Although nasal congestion may be bothersome, it is generally benign and not associated with serious health risks. This side effect does not warrant urgent consultation with the healthcare provider.
Correct Answer: D
Rationale: Urinary retention
Imipramine, a tricyclic antidepressant, can significantly affect bladder function, leading to urinary retention. This side effect poses serious risks, including urinary tract infections and bladder distension, necessitating immediate collaboration with the health care provider to manage the patient's safety effectively.
A: Dry mouth Commonly experienced with tricyclic antidepressants, dry mouth does not pose immediate health risks. It can be managed with hydration and oral care without necessitating urgent intervention.
B: Blurred vision While blurred vision can occur, it typically resolves without complications. This side effect is often manageable and does not usually indicate severe health concerns needing immediate escalation.
C: Nasal congestion Although nasal congestion may be bothersome, it is generally benign and not associated with serious health risks. This side effect does not warrant urgent consultation with the healthcare provider.
Question 10
Regular
A patient diagnosed with major depressive disorder tells the nurse, 'Bad things that happen are always my fault.' To assist the patient in reframing this overgeneralization, how should the nurse respond?
Correct!
Incorrect
The correct answer is: B
Rationale
Let's look at one bad thing that happened to see if another explanation exists.
This response encourages the patient to examine specific instances of their negative beliefs, promoting cognitive restructuring. By focusing on particular situations, the nurse helps the patient identify alternative explanations, thus challenging their overgeneralizations and fostering a more balanced perspective on their experiences.
A: I really doubt that one person can be blamed for all the bad things that happen. This statement may come across as dismissive and doesn't engage the patient in exploring their thoughts or feelings.
C: You are being exceptionally hard on yourself when you say those things. While this acknowledges the patient's feelings, it lacks the active engagement needed to help them reframe their thinking more effectively.
D: How does your belief in fate relate to your cultural heritage? This option diverts the conversation to cultural beliefs rather than addressing the patient's specific thought patterns and overgeneralizations that need reframing.
Correct Answer: B
Rationale: Let's look at one bad thing that happened to see if another explanation exists.
This response encourages the patient to examine specific instances of their negative beliefs, promoting cognitive restructuring. By focusing on particular situations, the nurse helps the patient identify alternative explanations, thus challenging their overgeneralizations and fostering a more balanced perspective on their experiences.
A: I really doubt that one person can be blamed for all the bad things that happen. This statement may come across as dismissive and doesn't engage the patient in exploring their thoughts or feelings.
C: You are being exceptionally hard on yourself when you say those things. While this acknowledges the patient's feelings, it lacks the active engagement needed to help them reframe their thinking more effectively.
D: How does your belief in fate relate to your cultural heritage? This option diverts the conversation to cultural beliefs rather than addressing the patient's specific thought patterns and overgeneralizations that need reframing.
Question 11
Regular
A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for what emotional response?
Correct!
Incorrect
The correct answer is: D
Rationale
A: Overinvolvement The nurse's professional boundaries are likely maintained, focusing on the patient's care rather than becoming overly emotionally attached, which reduces the likelihood of overinvolvement in this scenario.
B: Guilt and despair The situation does not typically induce feelings of guilt or despair in a professional who understands treatment limitations and recognizes the complexities of mental health recovery.
C: Disinterest and apathy A dedicated nurse is unlikely to develop disinterest or apathy after three weeks, particularly when the patient's lack of improvement may evoke a stronger commitment to finding solutions.
Correct Answer: D
Rationale: A: Overinvolvement The nurse's professional boundaries are likely maintained, focusing on the patient's care rather than becoming overly emotionally attached, which reduces the likelihood of overinvolvement in this scenario.
B: Guilt and despair The situation does not typically induce feelings of guilt or despair in a professional who understands treatment limitations and recognizes the complexities of mental health recovery.
C: Disinterest and apathy A dedicated nurse is unlikely to develop disinterest or apathy after three weeks, particularly when the patient's lack of improvement may evoke a stronger commitment to finding solutions.
Question 12
Regular
A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?
Correct!
Incorrect
The correct answer is: B
Rationale
Report increased suicidal thoughts. This directive is crucial as SSRIs can initially increase suicidal ideation in some patients, especially in younger individuals. Monitoring and reporting these thoughts ensure timely intervention and safety during treatment.
A: Avoid exposure to bright sunlight. While some medications may increase photosensitivity, SSRIs do not typically require this precaution, making it less relevant for patient safety and treatment adherence.
C: Restrict sodium intake to 1 g daily. Sodium restriction is not a standard recommendation for patients on SSRIs and does not address the primary concerns associated with their use in treating depression.
D: Maintain a tyramine-free diet. This dietary restriction is necessary for patients on monoamine oxidase inhibitors, not SSRIs, as the latter does not interact with tyramine, rendering this guidance unnecessary.
Correct Answer: B
Rationale: Report increased suicidal thoughts. This directive is crucial as SSRIs can initially increase suicidal ideation in some patients, especially in younger individuals. Monitoring and reporting these thoughts ensure timely intervention and safety during treatment.
A: Avoid exposure to bright sunlight. While some medications may increase photosensitivity, SSRIs do not typically require this precaution, making it less relevant for patient safety and treatment adherence.
C: Restrict sodium intake to 1 g daily. Sodium restriction is not a standard recommendation for patients on SSRIs and does not address the primary concerns associated with their use in treating depression.
D: Maintain a tyramine-free diet. This dietary restriction is necessary for patients on monoamine oxidase inhibitors, not SSRIs, as the latter does not interact with tyramine, rendering this guidance unnecessary.
Question 13
Regular
A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
Correct!
Incorrect
The correct answer is: A
Rationale
Mashed potatoes, ground beef patty, corn, green beans, and apple pie comprise a meal that adheres to a tyramine-restricted diet, as it lacks high-tyramine foods commonly found in processed meats and aged cheeses.
B: Avocado salad, ham, creamed potatoes, asparagus, chocolate cake contains ham, a processed meat that often has high tyramine levels, making it unsuitable for this diet.
C: Macaroni and cheese, hot dogs, banana bread, caffeinated coffee includes hot dogs and cheese, both of which can contain elevated levels of tyramine, conflicting with dietary restrictions.
D: Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls features smoked sausage and cheddar cheese, both known for their high tyramine content, rendering the meal inappropriate for the diet.
Correct Answer: A
Rationale: Mashed potatoes, ground beef patty, corn, green beans, and apple pie comprise a meal that adheres to a tyramine-restricted diet, as it lacks high-tyramine foods commonly found in processed meats and aged cheeses.
B: Avocado salad, ham, creamed potatoes, asparagus, chocolate cake contains ham, a processed meat that often has high tyramine levels, making it unsuitable for this diet.
C: Macaroni and cheese, hot dogs, banana bread, caffeinated coffee includes hot dogs and cheese, both of which can contain elevated levels of tyramine, conflicting with dietary restrictions.
D: Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls features smoked sausage and cheddar cheese, both known for their high tyramine content, rendering the meal inappropriate for the diet.
Question 14
Regular
What is the focus of priority nursing care for the period immediately after a patient has an electroconvulsive therapy (ECT) treatment?
Correct!
Incorrect
The correct answer is: A
Rationale
Supporting physiological stability is the focus of priority nursing care immediately after a patient has electroconvulsive therapy (ECT) treatment.
After ECT, patients may experience temporary physiological changes, including altered heart rate, blood pressure, and respiratory function. Ensuring physiological stability is crucial for patient safety and recovery, allowing for appropriate monitoring and intervention during this vulnerable period following the procedure.
B: Reducing disorientation and confusion. While reducing disorientation is important, it is secondary to ensuring the patient’s physiological stability immediately after ECT, which is critical for overall safety.
C: Monitoring pupillary responses. Although monitoring pupillary responses can offer insights into neurological function, it does not encompass the broader necessity of maintaining the patient's overall physiological stability during the immediate post-treatment phase.
D: Assisting the patient to plan for the future. Planning for the future is a significant aspect of patient care but does not address the urgent need for physiological stability immediately following ECT treatment.
Correct Answer: A
Rationale: Supporting physiological stability is the focus of priority nursing care immediately after a patient has electroconvulsive therapy (ECT) treatment.
After ECT, patients may experience temporary physiological changes, including altered heart rate, blood pressure, and respiratory function. Ensuring physiological stability is crucial for patient safety and recovery, allowing for appropriate monitoring and intervention during this vulnerable period following the procedure.
B: Reducing disorientation and confusion. While reducing disorientation is important, it is secondary to ensuring the patient’s physiological stability immediately after ECT, which is critical for overall safety.
C: Monitoring pupillary responses. Although monitoring pupillary responses can offer insights into neurological function, it does not encompass the broader necessity of maintaining the patient's overall physiological stability during the immediate post-treatment phase.
D: Assisting the patient to plan for the future. Planning for the future is a significant aspect of patient care but does not address the urgent need for physiological stability immediately following ECT treatment.
Question 15
Regular
A nurse provided medication education for a patient who is prescribed phenelzine for depression. Which patient behavior indicates effective learning?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Consults the pharmacist when selecting over-the-counter medications. This behavior demonstrates effective learning, as patients prescribed phenelzine must be cautious about drug interactions, particularly with over-the-counter options that could exacerbate side effects or reduce efficacy.
A: Monitors sodium intake and weight daily. While monitoring sodium and weight is important, it does not specifically relate to the key considerations for a patient on phenelzine.
B: Wears support stockings and elevates the legs when sitting. This action pertains to managing circulatory issues and is not directly relevant to the essential precautions needed for phenelzine users.
D: Can identify foods with high selenium content, which should be avoided. Phenelzine requires avoidance of tyramine-rich foods, not selenium, highlighting a misunderstanding of dietary restrictions associated with this medication.
Correct Answer: C
Rationale: C: Consults the pharmacist when selecting over-the-counter medications. This behavior demonstrates effective learning, as patients prescribed phenelzine must be cautious about drug interactions, particularly with over-the-counter options that could exacerbate side effects or reduce efficacy.
A: Monitors sodium intake and weight daily. While monitoring sodium and weight is important, it does not specifically relate to the key considerations for a patient on phenelzine.
B: Wears support stockings and elevates the legs when sitting. This action pertains to managing circulatory issues and is not directly relevant to the essential precautions needed for phenelzine users.
D: Can identify foods with high selenium content, which should be avoided. Phenelzine requires avoidance of tyramine-rich foods, not selenium, highlighting a misunderstanding of dietary restrictions associated with this medication.
Question 16
Regular
A patient's employment is terminated, and major depressive disorder develops shortly afterward. The patient says to the nurse, 'I'm not worth the time you spend with me. I'm the most useless person in the world.' Which nursing diagnosis applies?
Correct!
Incorrect
The correct answer is: C
Rationale
Situational low self-esteem. The patient's expression of worthlessness and feeling useless following job termination signifies a significant decline in self-worth, reflecting situational low self-esteem that stems from recent life changes.
A: Powerlessness. Although the patient feels inadequate, powerlessness refers more to a lack of control over circumstances rather than a diminished sense of self-worth based on recent events.
B: Defensive coping. This diagnosis involves avoiding stressors through denial or rationalization, which doesn't align with the patient's overt expression of hopelessness and low self-esteem following employment loss.
D: Disturbed personal identity. This diagnosis pertains to confusion about self-concept or identity, whereas the patient’s statements clearly indicate a negative evaluation of self-worth rather than identity confusion.
Correct Answer: C
Rationale: Situational low self-esteem. The patient's expression of worthlessness and feeling useless following job termination signifies a significant decline in self-worth, reflecting situational low self-esteem that stems from recent life changes.
A: Powerlessness. Although the patient feels inadequate, powerlessness refers more to a lack of control over circumstances rather than a diminished sense of self-worth based on recent events.
B: Defensive coping. This diagnosis involves avoiding stressors through denial or rationalization, which doesn't align with the patient's overt expression of hopelessness and low self-esteem following employment loss.
D: Disturbed personal identity. This diagnosis pertains to confusion about self-concept or identity, whereas the patient’s statements clearly indicate a negative evaluation of self-worth rather than identity confusion.
Question 17
Regular
A patient diagnosed with major depressive disorder 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. Select the nurse's most effective approach to communication.
Correct!
Incorrect
The correct answer is: A
Rationale
Make observations on neutral topics. This approach promotes a safe environment for the patient, allowing them to feel accepted without pressure. It encourages communication while respecting their current emotional state and limitations.
B: Ask the patient direct questions. Direct inquiries may overwhelm the patient, leading to further withdrawal or agitation instead of fostering an open dialogue.
C: Phrase questions to require 'yes' or 'no' answers. Limiting responses to binary options can stifle deeper communication and does not encourage the patient to express their feelings.
D: Frequently reassure the patient to reduce guilt feelings. Over-reassurance might feel insincere or intrusive, potentially causing the patient to withdraw further instead of fostering genuine communication.
Correct Answer: A
Rationale: Make observations on neutral topics. This approach promotes a safe environment for the patient, allowing them to feel accepted without pressure. It encourages communication while respecting their current emotional state and limitations.
B: Ask the patient direct questions. Direct inquiries may overwhelm the patient, leading to further withdrawal or agitation instead of fostering an open dialogue.
C: Phrase questions to require 'yes' or 'no' answers. Limiting responses to binary options can stifle deeper communication and does not encourage the patient to express their feelings.
D: Frequently reassure the patient to reduce guilt feelings. Over-reassurance might feel insincere or intrusive, potentially causing the patient to withdraw further instead of fostering genuine communication.
Question 18
Regular
A patient being treated for major depressive disorder has taken 300 mg amitriptyline 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.' How should the nurse advise the patient?
Correct!
Incorrect
The correct answer is: C
Rationale
Take one dose of the antidepressant, and then come to the clinic to see the health care provider. This advice addresses the potential withdrawal symptoms due to abrupt discontinuation of amitriptyline, allowing the patient to stabilize while ensuring a follow-up with a healthcare provider for further evaluation and management.
A: Go to the nearest emergency department immediately. While the symptoms may be concerning, they do not necessarily warrant emergency intervention, and the patient can manage this situation with proper guidance.
B: Do not to be alarmed. Take two aspirin and drink plenty of fluids. Aspirin is not appropriate for managing withdrawal symptoms from amitriptyline, and minimizing the patient's concerns could exacerbate anxiety about their condition.
D: Resume taking the antidepressant for 2 more weeks, and then discontinue it again. Gradual tapering is important, but abruptly resuming the medication without professional guidance could lead to further complications and discomfort for the patient.
Correct Answer: C
Rationale: Take one dose of the antidepressant, and then come to the clinic to see the health care provider. This advice addresses the potential withdrawal symptoms due to abrupt discontinuation of amitriptyline, allowing the patient to stabilize while ensuring a follow-up with a healthcare provider for further evaluation and management.
A: Go to the nearest emergency department immediately. While the symptoms may be concerning, they do not necessarily warrant emergency intervention, and the patient can manage this situation with proper guidance.
B: Do not to be alarmed. Take two aspirin and drink plenty of fluids. Aspirin is not appropriate for managing withdrawal symptoms from amitriptyline, and minimizing the patient's concerns could exacerbate anxiety about their condition.
D: Resume taking the antidepressant for 2 more weeks, and then discontinue it again. Gradual tapering is important, but abruptly resuming the medication without professional guidance could lead to further complications and discomfort for the patient.
Question 19
Regular
Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?
Correct!
Incorrect
The correct answer is: A
Rationale
Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. This documentation shows positive engagement and improved mood, indicating that the treatment plan for the patient’s major depressive disorder is effective and contributing to their overall well-being.
B: Slept 10 hours uninterrupted. Attended craft group; stated 'project was a failure, just like me.' Despite adequate sleep, negative self-perception suggests ongoing struggles with depression, indicating treatment ineffectiveness.
C: Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. Only minimal improvements in hygiene and slight weight loss reflect persistent challenges and limited treatment success.
D: Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, 'I feel tired all the time.' While sleep duration seems sufficient, ongoing feelings of inadequacy and fatigue highlight continued depressive symptoms.
Correct Answer: A
Rationale: Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild. This documentation shows positive engagement and improved mood, indicating that the treatment plan for the patient’s major depressive disorder is effective and contributing to their overall well-being.
B: Slept 10 hours uninterrupted. Attended craft group; stated 'project was a failure, just like me.' Despite adequate sleep, negative self-perception suggests ongoing struggles with depression, indicating treatment ineffectiveness.
C: Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound. Only minimal improvements in hygiene and slight weight loss reflect persistent challenges and limited treatment success.
D: Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, 'I feel tired all the time.' While sleep duration seems sufficient, ongoing feelings of inadequacy and fatigue highlight continued depressive symptoms.
Question 20
Regular
A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, 'I feel like a failure. This baby is the root of my problems.' What is the priority nursing diagnosis?
Correct!
Incorrect
The correct answer is: D
Rationale
Risk for other-directed violence. The woman’s expression of feeling like a failure and attributing her problems to the baby indicates potential aggression or harm towards herself or others, necessitating immediate attention to prevent violence.
A: Insomnia. While the woman reports an inability to sleep, this symptom alone does not address the underlying emotional crisis or potential for harm, which is more pressing.
B: Ineffective coping. Although she struggles with coping, the specific mention of feeling like a failure and the risk of violence indicates a more critical focus on safety and immediate risk.
C: Situational low self-esteem. The feelings of inadequacy are significant, but they do not directly imply a risk of harm to herself or others, which is paramount in this situation.
Correct Answer: D
Rationale: Risk for other-directed violence. The woman’s expression of feeling like a failure and attributing her problems to the baby indicates potential aggression or harm towards herself or others, necessitating immediate attention to prevent violence.
A: Insomnia. While the woman reports an inability to sleep, this symptom alone does not address the underlying emotional crisis or potential for harm, which is more pressing.
B: Ineffective coping. Although she struggles with coping, the specific mention of feeling like a failure and the risk of violence indicates a more critical focus on safety and immediate risk.
C: Situational low self-esteem. The feelings of inadequacy are significant, but they do not directly imply a risk of harm to herself or others, which is paramount in this situation.
Question 21
Regular
A patient diagnosed with major depressive disorder repeatedly tells staff members, 'I have cancer. It's my punishment for being a bad person.' Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
Correct!
Incorrect
The correct answer is: B
Rationale
B: Risk for suicide. The patient's expression of having cancer as a punishment indicates profound despair and potential hopelessness, making the risk for suicide a critical concern that requires immediate nursing intervention.
A: Powerlessness. While the patient may feel powerless, the emphasis on punishment for perceived wrongdoing suggests a more urgent need to address suicidal ideation rather than mere feelings of helplessness.
C: Stress overload. Although the patient is likely experiencing significant emotional strain, the focus on self-punishment points more directly to suicidal thoughts, necessitating a priority on safety rather than stress management.
D: Spiritual distress. Spiritual concerns may be present, yet the direct implication of self-punishment due to perceived moral failings highlights a more pressing need to ensure the patient's safety and mental health.
Correct Answer: B
Rationale: B: Risk for suicide. The patient's expression of having cancer as a punishment indicates profound despair and potential hopelessness, making the risk for suicide a critical concern that requires immediate nursing intervention.
A: Powerlessness. While the patient may feel powerless, the emphasis on punishment for perceived wrongdoing suggests a more urgent need to address suicidal ideation rather than mere feelings of helplessness.
C: Stress overload. Although the patient is likely experiencing significant emotional strain, the focus on self-punishment points more directly to suicidal thoughts, necessitating a priority on safety rather than stress management.
D: Spiritual distress. Spiritual concerns may be present, yet the direct implication of self-punishment due to perceived moral failings highlights a more pressing need to ensure the patient's safety and mental health.
Question 22
Regular
Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Milk is a nutrient-rich option that provides protein, calcium, and essential vitamins, making it beneficial for patients with major depressive disorder who may lack solid food intake. Its mild taste can encourage consumption.
A: Tomato juice lacks the necessary calories and protein that a patient needs, potentially failing to provide adequate nutritional support during a time when solid food is refused.
B: Orange juice, while high in vitamin C, does not offer sufficient protein or calories and may not satisfy a patient's nutritional needs adequately compared to more substantial beverages.
C: Hot tea, although comforting, offers minimal nutritional value and lacks the essential calories and nutrients required by a patient in a vulnerable state who is refusing solid food.
Correct Answer: D
Rationale: D: Milk is a nutrient-rich option that provides protein, calcium, and essential vitamins, making it beneficial for patients with major depressive disorder who may lack solid food intake. Its mild taste can encourage consumption.
A: Tomato juice lacks the necessary calories and protein that a patient needs, potentially failing to provide adequate nutritional support during a time when solid food is refused.
B: Orange juice, while high in vitamin C, does not offer sufficient protein or calories and may not satisfy a patient's nutritional needs adequately compared to more substantial beverages.
C: Hot tea, although comforting, offers minimal nutritional value and lacks the essential calories and nutrients required by a patient in a vulnerable state who is refusing solid food.
Question 23
Regular
During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, 'Life feels so hopeless to me. I've been feeling sad for several months.' How should the nurse document the patient's affect and mood?
Correct!
Incorrect
The correct answer is: B
Rationale
Affect flat; mood depressed. The patient's description of feeling hopeless and sad for several months, combined with their emotionless facial expressions, indicates a lack of emotional responsiveness, indicative of a flat affect, while their mood is clearly depressed.
A: Affect depressed; mood flat. A depressed affect implies visible sadness or emotional expression, which contradicts the patient’s emotionless facial demeanor observed during the assessment.
C: Affect labile; mood euphoric. A labile affect signifies rapid mood changes, while the patient displays a consistent lack of emotion; thus, no evidence supports euphoric mood or shifting affect.
D: Affect and mood are incongruent. Both affect and mood align with the observations; flat affect matches the depressed mood, making incongruence an inaccurate characterization of the patient's emotional state.
Correct Answer: B
Rationale: Affect flat; mood depressed. The patient's description of feeling hopeless and sad for several months, combined with their emotionless facial expressions, indicates a lack of emotional responsiveness, indicative of a flat affect, while their mood is clearly depressed.
A: Affect depressed; mood flat. A depressed affect implies visible sadness or emotional expression, which contradicts the patient’s emotionless facial demeanor observed during the assessment.
C: Affect labile; mood euphoric. A labile affect signifies rapid mood changes, while the patient displays a consistent lack of emotion; thus, no evidence supports euphoric mood or shifting affect.
D: Affect and mood are incongruent. Both affect and mood align with the observations; flat affect matches the depressed mood, making incongruence an inaccurate characterization of the patient's emotional state.
Question 24
Regular
A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. What action should the nurse take?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Firmly and neutrally assisting the patient with showering. This approach provides necessary support while respecting the patient's autonomy. It addresses hygiene needs without confrontation, fostering a sense of safety and trust in the therapeutic relationship.
A: Avoid forcing the issue. This neglects the patient's hygiene needs and may exacerbate feelings of hopelessness, undermining the potential for improvement in their overall mental health.
B: Bringing up the issue at the community meeting. Discussing personal hygiene in a public setting can lead to embarrassment for the patient, potentially increasing their distress and worsening their condition.
C: Calmly telling the patient, 'You must bathe daily.' This directive may feel overwhelming or demanding to the patient, failing to provide the supportive, hands-on assistance they require to engage in self-care.
Correct Answer: D
Rationale: D: Firmly and neutrally assisting the patient with showering. This approach provides necessary support while respecting the patient's autonomy. It addresses hygiene needs without confrontation, fostering a sense of safety and trust in the therapeutic relationship.
A: Avoid forcing the issue. This neglects the patient's hygiene needs and may exacerbate feelings of hopelessness, undermining the potential for improvement in their overall mental health.
B: Bringing up the issue at the community meeting. Discussing personal hygiene in a public setting can lead to embarrassment for the patient, potentially increasing their distress and worsening their condition.
C: Calmly telling the patient, 'You must bathe daily.' This directive may feel overwhelming or demanding to the patient, failing to provide the supportive, hands-on assistance they require to engage in self-care.
Question 25
Regular
A patient was started on escitalopram 5 days ago and now says, 'This medicine isn't working.' What is the nurse's best intervention?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Explaining the time lag before antidepressants relieve symptoms.
Antidepressants like escitalopram often require several weeks for full efficacy. By educating the patient about this delay, the nurse can help manage expectations and reduce anxiety regarding treatment.
A: Discussing with the health care provider the need to change medications.
This option prematurely considers medication alteration without allowing enough time for the current treatment to take effect, which could hinder the patient's progress.
B: Reassuring the patient that the medication will be effective soon.
While reassurance is important, it lacks the educational component about the necessary time frame for medication effectiveness, potentially leading to misunderstandings about treatment timelines.
D: Critically assessing the patient for symptom relief.
Although assessment is vital, the immediate focus should be on patient education regarding the expected timeline for relief rather than evaluating symptoms at this early stage.
Correct Answer: C
Rationale: C: Explaining the time lag before antidepressants relieve symptoms.
Antidepressants like escitalopram often require several weeks for full efficacy. By educating the patient about this delay, the nurse can help manage expectations and reduce anxiety regarding treatment.
A: Discussing with the health care provider the need to change medications.
This option prematurely considers medication alteration without allowing enough time for the current treatment to take effect, which could hinder the patient's progress.
B: Reassuring the patient that the medication will be effective soon.
While reassurance is important, it lacks the educational component about the necessary time frame for medication effectiveness, potentially leading to misunderstandings about treatment timelines.
D: Critically assessing the patient for symptom relief.
Although assessment is vital, the immediate focus should be on patient education regarding the expected timeline for relief rather than evaluating symptoms at this early stage.
Question 26
Regular
A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate?
Correct!
Incorrect
The correct answer is: D
Rationale
Eyes casted downward. This nonverbal cue often signifies feelings of shame, insecurity, or low self-worth, which are common in individuals with low self-esteem. It highlights their discomfort and reluctance to engage openly.
A: Arms crossed. This gesture typically indicates defensiveness or a desire for personal space, rather than directly reflecting low self-esteem, which is more about internalized feelings of inadequacy.
B: Staring at the nurse. Such behavior may suggest confidence or assertiveness, contrasting with low self-esteem. It can indicate an attempt to dominate the interaction rather than reflect feelings of inferiority.
C: Smiling inappropriately. This behavior often denotes nervousness or social awkwardness, not necessarily low self-esteem. Individuals with low self-esteem may struggle to express genuine emotions instead of displaying an unnatural smile.
Correct Answer: D
Rationale: Eyes casted downward. This nonverbal cue often signifies feelings of shame, insecurity, or low self-worth, which are common in individuals with low self-esteem. It highlights their discomfort and reluctance to engage openly.
A: Arms crossed. This gesture typically indicates defensiveness or a desire for personal space, rather than directly reflecting low self-esteem, which is more about internalized feelings of inadequacy.
B: Staring at the nurse. Such behavior may suggest confidence or assertiveness, contrasting with low self-esteem. It can indicate an attempt to dominate the interaction rather than reflect feelings of inferiority.
C: Smiling inappropriately. This behavior often denotes nervousness or social awkwardness, not necessarily low self-esteem. Individuals with low self-esteem may struggle to express genuine emotions instead of displaying an unnatural smile.
Question 27
Regular
A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
Correct!
Incorrect
The correct answer is: A
Rationale
Temporary memory impairments and confusion can be associated with electroconvulsive therapy. These side effects can impact cognitive functions, making it difficult for the patient to make sound decisions during recovery.
B: Antidepressant medications alter catecholamine levels, which impair decision-making abilities. While these medications can influence mood, they do not specifically lead to immediate decision-making impairments that would warrant a month-long pause.
C: Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. This dietary restriction primarily prevents adverse reactions and does not directly link to decision-making capabilities or cognitive clarity.
D: The patient needs time to reorient him or herself to a pressured work schedule. Although reorientation may be beneficial, the primary concern lies with the cognitive effects of the recent therapy rather than work pressure.
Correct Answer: A
Rationale: Temporary memory impairments and confusion can be associated with electroconvulsive therapy. These side effects can impact cognitive functions, making it difficult for the patient to make sound decisions during recovery.
B: Antidepressant medications alter catecholamine levels, which impair decision-making abilities. While these medications can influence mood, they do not specifically lead to immediate decision-making impairments that would warrant a month-long pause.
C: Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. This dietary restriction primarily prevents adverse reactions and does not directly link to decision-making capabilities or cognitive clarity.
D: The patient needs time to reorient him or herself to a pressured work schedule. Although reorientation may be beneficial, the primary concern lies with the cognitive effects of the recent therapy rather than work pressure.
Question 28
Regular
A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of what risk?
Correct!
Incorrect
The correct answer is: B
Rationale
A hypertensive crisis. This risk arises because MAO inhibitors can lead to dangerously high blood pressure when combined with tyramine-rich foods, resulting in severe hypertension and related complications if not avoided.
A: Hypotensive shock. This condition typically results from low blood pressure rather than the interaction of MAO inhibitors with certain foods, making it an unlikely risk in this scenario.
C: Cardiac dysrhythmia. While some medications may influence heart rhythm, the primary concern with MAO inhibitors relates to blood pressure spikes rather than rhythm disturbances from food interactions.
D: Cardiogenic shock. This severe state arises from the heart's inability to pump effectively, which does not directly relate to the dietary restrictions associated with monoamine oxidase inhibitors.
Correct Answer: B
Rationale: A hypertensive crisis. This risk arises because MAO inhibitors can lead to dangerously high blood pressure when combined with tyramine-rich foods, resulting in severe hypertension and related complications if not avoided.
A: Hypotensive shock. This condition typically results from low blood pressure rather than the interaction of MAO inhibitors with certain foods, making it an unlikely risk in this scenario.
C: Cardiac dysrhythmia. While some medications may influence heart rhythm, the primary concern with MAO inhibitors relates to blood pressure spikes rather than rhythm disturbances from food interactions.
D: Cardiogenic shock. This severe state arises from the heart's inability to pump effectively, which does not directly relate to the dietary restrictions associated with monoamine oxidase inhibitors.
Question 29
Multiple Choice
The admission note indicates a patient diagnosed with major depressive disorder has displayed symptomology of both anergia and anhedonia. For which measures should the nurse plan?
Correct!
Incorrect
The correct answer is: C,D,E
Rationale
C: Instilling a sense of hopefulness is essential for a patient with major depressive disorder, as it can combat feelings of despair and motivate recovery. This approach fosters resilience and engagement in treatment.
A: Channeling excessive energy does not align with the symptoms of anergia and anhedonia, as these conditions reflect low energy and lack of pleasure rather than excessive energy.
B: Reducing guilty ruminations may be helpful, but it does not directly address the primary symptoms of anergia and anhedonia that the patient is experiencing, limiting its effectiveness.
D: Assisting with self-care activities is crucial for patients struggling with major depressive disorder, as it promotes routine and self-management, aiding in their overall recovery process and improving their quality of life.
E: Accommodating psychomotor retardation is vital for patients displaying slowed movements and processing, ensuring they are supported without feeling pressured, which can enhance their comfort and safety during treatment.
Correct Answer: C,D,E
Rationale: C: Instilling a sense of hopefulness is essential for a patient with major depressive disorder, as it can combat feelings of despair and motivate recovery. This approach fosters resilience and engagement in treatment.
A: Channeling excessive energy does not align with the symptoms of anergia and anhedonia, as these conditions reflect low energy and lack of pleasure rather than excessive energy.
B: Reducing guilty ruminations may be helpful, but it does not directly address the primary symptoms of anergia and anhedonia that the patient is experiencing, limiting its effectiveness.
D: Assisting with self-care activities is crucial for patients struggling with major depressive disorder, as it promotes routine and self-management, aiding in their overall recovery process and improving their quality of life.
E: Accommodating psychomotor retardation is vital for patients displaying slowed movements and processing, ensuring they are supported without feeling pressured, which can enhance their comfort and safety during treatment.
Question 30
Multiple Choice
A student nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, 'This patient shows vegetative signs of depression.' Which nursing diagnoses most clearly relate to the vegetative signs?
Correct!
Incorrect
The correct answer is: A,C,D,F
Rationale
Vegetative signs of depression often involve symptoms affecting basic physiological functions, particularly in nutrition, sleep, and self-care. Therefore, nursing diagnoses such as imbalanced nutrition, self-care deficit, and insomnia are directly relevant to these manifestations of the disorder.
B: Chronic low self-esteem focuses on emotional and psychological aspects rather than the physical symptoms associated with vegetative signs of depression, making it less relevant in this context.
C: Sexual dysfunction pertains to interpersonal and sexual health issues, not the physiological indicators of depression that vegetative signs represent, thus lacking direct correlation with the diagnosis.
E: Powerlessness relates to a sense of lack of control and agency, which does not directly address the physical symptoms or functional impairments inherent in vegetative signs.
F: Insomnia, while a symptom of depression, is specifically about sleep disturbances rather than the broader scope of vegetative signs, which encompass multiple physiological functions beyond just sleep.
Correct Answer: A,C,D,F
Rationale: Vegetative signs of depression often involve symptoms affecting basic physiological functions, particularly in nutrition, sleep, and self-care. Therefore, nursing diagnoses such as imbalanced nutrition, self-care deficit, and insomnia are directly relevant to these manifestations of the disorder.
B: Chronic low self-esteem focuses on emotional and psychological aspects rather than the physical symptoms associated with vegetative signs of depression, making it less relevant in this context.
C: Sexual dysfunction pertains to interpersonal and sexual health issues, not the physiological indicators of depression that vegetative signs represent, thus lacking direct correlation with the diagnosis.
E: Powerlessness relates to a sense of lack of control and agency, which does not directly address the physical symptoms or functional impairments inherent in vegetative signs.
F: Insomnia, while a symptom of depression, is specifically about sleep disturbances rather than the broader scope of vegetative signs, which encompass multiple physiological functions beyond just sleep.
Question 31
Multiple Choice
A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment?
Correct!
Incorrect
The correct answer is: A,B,C
Rationale
Administer pretreatment medication 30 to 45 minutes before treatment. This intervention is essential for optimizing the patient's comfort and safety, as the medication helps mitigate potential side effects of the electroconvulsive therapy, ensuring a smoother treatment experience.
D: Restrain the patient in bed with padded limb restraints. This approach is unnecessary and inappropriate, as patients typically do not require physical restraints before electroconvulsive therapy unless there are specific behavioral concerns.
E: Assist the patient to prepare an advance directive. While advance directives are important, they are not a routine intervention performed immediately before electroconvulsive therapy, as the focus is on immediate treatment preparation.
Correct Answer: A,B,C
Rationale: Administer pretreatment medication 30 to 45 minutes before treatment. This intervention is essential for optimizing the patient's comfort and safety, as the medication helps mitigate potential side effects of the electroconvulsive therapy, ensuring a smoother treatment experience.
D: Restrain the patient in bed with padded limb restraints. This approach is unnecessary and inappropriate, as patients typically do not require physical restraints before electroconvulsive therapy unless there are specific behavioral concerns.
E: Assist the patient to prepare an advance directive. While advance directives are important, they are not a routine intervention performed immediately before electroconvulsive therapy, as the focus is on immediate treatment preparation.
Question 32
Multiple Choice
A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented?
Correct!
Incorrect
The correct answer is: A,B,C
Rationale
Monitor food and fluid intake. This action is vital for patients with major depressive disorder showing vegetative signs, as they often neglect basic self-care, impacting their overall health and recovery.
A: Offer laxatives, if needed. While addressing constipation may be necessary, it does not directly support the immediate nutritional needs or hydration concerns critical in depressive states.
D: Eliminate all daily caffeine intake. Caffeine restrictions may not be universally beneficial; some patients might rely on it for minimal energy boosts, and abrupt cessation could yield withdrawal symptoms.
E: Restrict the intake of processed foods. While healthier dietary choices are advisable, focusing on processed foods diverts attention from more pressing issues surrounding food intake and hydration in these patients.
Correct Answer: A,B,C
Rationale: Monitor food and fluid intake. This action is vital for patients with major depressive disorder showing vegetative signs, as they often neglect basic self-care, impacting their overall health and recovery.
A: Offer laxatives, if needed. While addressing constipation may be necessary, it does not directly support the immediate nutritional needs or hydration concerns critical in depressive states.
D: Eliminate all daily caffeine intake. Caffeine restrictions may not be universally beneficial; some patients might rely on it for minimal energy boosts, and abrupt cessation could yield withdrawal symptoms.
E: Restrict the intake of processed foods. While healthier dietary choices are advisable, focusing on processed foods diverts attention from more pressing issues surrounding food intake and hydration in these patients.
Question 33
Multiple Choice
A patient being treated with paroxetine 50 mg/day orally for major depressive disorder reports to the clinic nurse, 'I took a few extra tablets earlier in the day and now I feel bad.' Which aspects of the nursing assessment are most critical?
Correct!
Incorrect
The correct answer is: A,D,E
Rationale
A: Vital signs, presence of abdominal pain and diarrhea, and hyperactivity or feelings of restlessness are the most critical aspects of the nursing assessment for this patient.
Correct Option Explanation: Monitoring vital signs is essential to detect any physiological changes due to potential overdose. Assessing for abdominal pain and diarrhea helps identify gastrointestinal side effects. Evaluating hyperactivity or restlessness indicates possible serotonin syndrome, which requires immediate intervention.
B: Urinary frequency does not directly correlate with paroxetine overdose symptoms and is less critical in assessing the immediate risks related to the patient's reported condition.
C: Increased suicidal ideation is a significant concern in depression but does not specifically relate to the acute effects of taking extra paroxetine tablets in this situation.
E: Hyperactivity or feelings of restlessness are critical indicators in the context of potential serotonin syndrome, aligning with the need for prompt assessment of the patient's neurological status.
Correct Answer: A,D,E
Rationale: A: Vital signs, presence of abdominal pain and diarrhea, and hyperactivity or feelings of restlessness are the most critical aspects of the nursing assessment for this patient.
Correct Option Explanation: Monitoring vital signs is essential to detect any physiological changes due to potential overdose. Assessing for abdominal pain and diarrhea helps identify gastrointestinal side effects. Evaluating hyperactivity or restlessness indicates possible serotonin syndrome, which requires immediate intervention.
B: Urinary frequency does not directly correlate with paroxetine overdose symptoms and is less critical in assessing the immediate risks related to the patient's reported condition.
C: Increased suicidal ideation is a significant concern in depression but does not specifically relate to the acute effects of taking extra paroxetine tablets in this situation.
E: Hyperactivity or feelings of restlessness are critical indicators in the context of potential serotonin syndrome, aligning with the need for prompt assessment of the patient's neurological status.