Which nursing diagnosis should a nurse give highest prior when caring for a client with major depressive disorder?
Potential for injury
A client is newly prescribed tramadol hydrochloride (Ultram) for chronic pain. The client is also taking fluoxetine (Prozac) 40 mg daily for depression. Which statement by the nurse accurately explains the interactions between the two drugs?
This drug combination can increase the risk of serotonin syndrome.
A nurse is education a client about prescription antidepressant medications and the appropriate expectations when taking these. Which statement by the nurse is accurate?
It is important to continue taking antidepressant medication even after you feel better.
An experienced nurse is teaching a new nurse about establishing therapeutic relationships with clients on a mental health unit. Which intervention should the nurse suggest when attempting to establish a therapeutic relationship with a client diagnosed with major depressive disorder?
Sit with the client in silence.
A client recently diagnosed with depression tells a nurse that she is 2 months pregnant and is reluctant to take an antidepressant medication. The client asks what other treatment options are available. Which type of therapy should a nurse recommend as an alternate treatment for depression?
Cognitive behavioral therapy
A client diagnosed with major depressive disorder has a nursing diagnosis of Disturbed Sleep Pattern. When developing a plan of care for the client, which nursing actions are most appropriate? Select all that apply.
Determine sleep patterns prior to hospitalization.
Discourage sleeping during the day.
Record and limit caffeinated drinks.
Encourage measures that aid in relaxation.
A nurse assessing a client with dysthymia who reports symptoms of depressed mood. Which assessment finding supports the essential feature of dysthymia?
Chronically depressed mood for most of the day for a least 2 years.
A nurse is educating a client diagnosed with depression who is experiencing insomnia. Which intervention should the nurse recommend to reduce episodes of insomnia?
Maintain regular bedtime hours.
A nurse is assessing a client with suspected major depression. Which finding would support a diagnosis of major depression? Select all that apply.
Loss of interest or pleasure nearly daily for at least 2 weeks
Presence of psychomotor agitation nearly daily for at least 2 weeks.
Feelings of worthlessness nearly daily for at least 2 weeks
Impaired concentration nearly daily for at least 2 weeks
A nurse is assessing a client, attempting to differentiate the client’s symptoms between delirium and depression. Which symptoms of the client are unique to depression? Select all that apply.
Sadness
Lack of motivation
A nurse is assessing a client for suspected depression. The client is recently divorced and has a court appearance for a driving while intoxicated (DWI) charge the following week. Which response by the nurse is most therapeutic?
I’m concerned about your drinking. I’d like you to talk with our chemical dependency staff.
A nurse is teaching a class to assistive personnel on depression. Which statements by the nurse provide accurate information about depression? Select all that apply.
Women are approximately twice as likely as men to develop depression.
The rate of depression among adolescents increases with age.
Children in all age groups can become depressed.
A nurse observes that a client diagnosed with major depressive disorder who recently stated on an antidepressant is acting differently. Two days ago, the client appeared sad and remained in bed. Now the client is awake at 4 a.m. and planning a unit party. What is the most likely explanation for the change in behavior?
The client was misdiagnosed and what was thought to be a depression is bipolar disorder.
A nurse is assessing a client’s alcohol intake as part of a routine screening examination. The client reports drinking 3 to 4 beers; five times per week. The client is being treated for depression with sertraline (Zoloft) 100mg daily. Which statement by the nurse about the client’s alcohol consumption is accurate?
Alcohol worsens depression and makes treatment of depression more difficult.
A nurse is developing a care plan for an older adult female client diagnosed with depression. The inclusion of the nursing diagnosis Risk for injury due to osteopenia demonstrates that the nurse understands which evidence-based concept related to the client’s medical diagnosis?
Geriatric female clients with hip bone loss are at increased risk for depression.
A nurse is meeting with a client who is being discharged after hospitalization for suicidal ideation. Based on knowledge of expert consensus of warning signs for suicide, the nurse should plan to advise the client to seek help by contacting a metal health professional or calling the national suicide prevention hotline if experiencing: Select all that apply.
Hopelessness
Severe anxiety and agitation
Feelings of being trapped
Increasing alcohol or drug use
Reference
Davis’s Q & A For The NCLEX-RN EXAMINATION
Psychosocial Integrity: Care of Adults and Children with Mental Health Disorders
Pg 627 – 638
5 Signs and Symptoms of ICP
1. Decresed LOC (Confusion, restlessness, lethargy)
2. Pupils become sluggish to light
3. Motor impairment which can progress to Decoritcate of decerebrate positioning
4. Cushing's triad/response. (Increased systolic BP, widening pulse pressure, bradycardia)
5. Respirations become altered
Three positions contraindicated for a patient with ICP are: Trendelebourg (feet elevated), Supine (flat), Prone (lying on the stomach).
Potential for injury
A client is newly prescribed tramadol hydrochloride (Ultram) for chronic pain. The client is also taking fluoxetine (Prozac) 40 mg daily for depression. Which statement by the nurse accurately explains the interactions between the two drugs?
This drug combination can increase the risk of serotonin syndrome.
A nurse is education a client about prescription antidepressant medications and the appropriate expectations when taking these. Which statement by the nurse is accurate?
It is important to continue taking antidepressant medication even after you feel better.
An experienced nurse is teaching a new nurse about establishing therapeutic relationships with clients on a mental health unit. Which intervention should the nurse suggest when attempting to establish a therapeutic relationship with a client diagnosed with major depressive disorder?
Sit with the client in silence.
A client recently diagnosed with depression tells a nurse that she is 2 months pregnant and is reluctant to take an antidepressant medication. The client asks what other treatment options are available. Which type of therapy should a nurse recommend as an alternate treatment for depression?
Cognitive behavioral therapy
A client diagnosed with major depressive disorder has a nursing diagnosis of Disturbed Sleep Pattern. When developing a plan of care for the client, which nursing actions are most appropriate? Select all that apply.
Determine sleep patterns prior to hospitalization.
Discourage sleeping during the day.
Record and limit caffeinated drinks.
Encourage measures that aid in relaxation.
A nurse assessing a client with dysthymia who reports symptoms of depressed mood. Which assessment finding supports the essential feature of dysthymia?
Chronically depressed mood for most of the day for a least 2 years.
A nurse is educating a client diagnosed with depression who is experiencing insomnia. Which intervention should the nurse recommend to reduce episodes of insomnia?
Maintain regular bedtime hours.
A nurse is assessing a client with suspected major depression. Which finding would support a diagnosis of major depression? Select all that apply.
Loss of interest or pleasure nearly daily for at least 2 weeks
Presence of psychomotor agitation nearly daily for at least 2 weeks.
Feelings of worthlessness nearly daily for at least 2 weeks
Impaired concentration nearly daily for at least 2 weeks
A nurse is assessing a client, attempting to differentiate the client’s symptoms between delirium and depression. Which symptoms of the client are unique to depression? Select all that apply.
Sadness
Lack of motivation
A nurse is assessing a client for suspected depression. The client is recently divorced and has a court appearance for a driving while intoxicated (DWI) charge the following week. Which response by the nurse is most therapeutic?
I’m concerned about your drinking. I’d like you to talk with our chemical dependency staff.
A nurse is teaching a class to assistive personnel on depression. Which statements by the nurse provide accurate information about depression? Select all that apply.
Women are approximately twice as likely as men to develop depression.
The rate of depression among adolescents increases with age.
Children in all age groups can become depressed.
A nurse observes that a client diagnosed with major depressive disorder who recently stated on an antidepressant is acting differently. Two days ago, the client appeared sad and remained in bed. Now the client is awake at 4 a.m. and planning a unit party. What is the most likely explanation for the change in behavior?
The client was misdiagnosed and what was thought to be a depression is bipolar disorder.
A nurse is assessing a client’s alcohol intake as part of a routine screening examination. The client reports drinking 3 to 4 beers; five times per week. The client is being treated for depression with sertraline (Zoloft) 100mg daily. Which statement by the nurse about the client’s alcohol consumption is accurate?
Alcohol worsens depression and makes treatment of depression more difficult.
A nurse is developing a care plan for an older adult female client diagnosed with depression. The inclusion of the nursing diagnosis Risk for injury due to osteopenia demonstrates that the nurse understands which evidence-based concept related to the client’s medical diagnosis?
Geriatric female clients with hip bone loss are at increased risk for depression.
A nurse is meeting with a client who is being discharged after hospitalization for suicidal ideation. Based on knowledge of expert consensus of warning signs for suicide, the nurse should plan to advise the client to seek help by contacting a metal health professional or calling the national suicide prevention hotline if experiencing: Select all that apply.
Hopelessness
Severe anxiety and agitation
Feelings of being trapped
Increasing alcohol or drug use
Reference
Davis’s Q & A For The NCLEX-RN EXAMINATION
Psychosocial Integrity: Care of Adults and Children with Mental Health Disorders
Pg 627 – 638
5 Signs and Symptoms of ICP
1. Decresed LOC (Confusion, restlessness, lethargy)
2. Pupils become sluggish to light
3. Motor impairment which can progress to Decoritcate of decerebrate positioning
4. Cushing's triad/response. (Increased systolic BP, widening pulse pressure, bradycardia)
5. Respirations become altered
Three positions contraindicated for a patient with ICP are: Trendelebourg (feet elevated), Supine (flat), Prone (lying on the stomach).