The Client With Major Depression
A 63 year-old client comes to the neighborhood health center for his annual physical examination:
1. While interacting with the nurse, the client states that that he feels tired all of the time, has trouble sleeping and has a problem with thinking. The best nursing answer action is:
1.inform the client about the normal aging process
2.further assess the client's mental status and health history
3.refer the client to a senior citizens support group
4.advice the client to discontinue daytime napping.
(The answer is 2. The client is exhibiting signs of possible depression. The nurse should explore his medical history and conduct a mental status examination to further asses and explore his possibility . He is not exhibiting signs and symptoms of the normal aging process. Referral to a senior citizens support group may be appropriate later,depending to the client's needs and interests. Daytime napping should be discouraged if it interrupts nighttime sleeping. At this time, the nurse does not have enough information about the client's daily schedule to warrant napping being a problem. It is more important to first determine the source of his symptoms so that the client can be treated appropriately).
2. During the nurse's conversation with the client , the client sates. " I have no reason to be sad. I have to great job and a wonderful wife and family." Which of the following comments would be best for the nurse to make at this time
1."why do you think you're depressed"
2."think about how fortunate you are"
3."you have many positive qualities"
4."Depression can be caused by a chemical imbalance in the brain"
( The answer is 4. The biologic theory of depression indicates a neurotransmitter imbalance involving serotonin ,nor epinephrine, and possibly dopamine.Endogenous depression(depression coming from within the person) is biochemical in nature. Asking the client why he is depressed is non therapeutic because there is no external cause or reason for the client's depression and it will only increase the client's feelings of guilt for not being able to answer the nurse. Telling the client that he is fortunate and has positive qualities is not helpful and will not decrease his sadness of feelings of depression because it is biologically based).
3.The client is taking Sertraline (zoloft), 50 mg q AM. The nurse includes which of the following in the teaching in the plan about Zoloft.
1.zoloft may cause erectile and ejaculatory dysfunction in some men.
2.it may be 3 to 4 weeks after starting Zoloft before the client feels better.
3.zoloft cause light headedness or dizziness when rising.
4.zoloft increases the appetite and causes weight gain.
(The answer is 1.To promote medication compliance and treatment of depression , it is important for the male client to know that zoloft may cause loss of libido, erectile dysfunction, and ejaculatory dysfunction. A decrease in dosage can decrease these symptoms.Zoloft typically take 1 to 2 week to work before benefit are noted. Tricyclic anti depressant take 2 to 4 weeks before the patient receives maximum benefits , cause postural hypotension,and may cause weight gain).
4. The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate a correct understanding of her husband's illness and medication:
1."his depression is almost cured"
2."he's intelligent and won't need to depend on a pill much longer"
3."it's important for him to take his medication so that the depression will not return or get worse"
4 "it's important to watch for physical dependency on Zoloft"
(The answer is 3. Medication compliance is essential to prevent a return or worsening of the symptoms of endogenous depression. Maintaining biochemical balance can occur with medication. Depression is not cured and is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addicting).
The client was admitted to the psychiatric unit yesterday. The nurse observes that his head is bowed in a dejected manner,his facial expression is sad, and he is isolates him self in his room.
5. After a few minutes of conversation, the client wearily ask the nurse, "Why pick me to talk to when there are so many other people here". which reply by the nurse would be best:
1."I'm assign to care for you to day, if you'll let me"
2."you have a lot of potential, and I'd like to help you"
3."why shouldn't I want to talk to you, as well as the others"
4."you're wondering why I'm interested in you and not the others".
(The answer is 4.The nurse is using therapeutic technique of restatement when reiterating the client's comment in the form of a question. The the technique best help the client continue the conversation with expression of his feelings.Telling the client that the nurse is assigned to care for him and why is impersonal and implies that the client is being uncooperative.Telling the client that the nurse is there because the client has potential for improvement implies that others client perhaps do not have this potential.Asking the client a question with the word 'why' challenges him and demands an explanation.None of these approaches is as effective as using the technique of restatement).
6. The Nurse meets with the client daily. The client stays mostly in his room and speaks only when addresses, answering briefly and abruptly while keeping his eyes on the floor.In this stage of their relationship.the nurse focuses on the client's ability to
1.make decisions
2.relate to other clients
3.function independently
4.express himself verbally.
(The answer is 4.when working with a client who speak little,answer briefly, and loot at the floor,the nurse should focus on the simplest type of behavior (ie,behavior requiring the least effort for the client).
The relationship described in this items is the orientation phase. when self-expression and verbalization are more appropriate goals,then decision making,relating to others,and functioning independently may be pursued).
7. Which of the following client behaviors would best indicate to the nurse that the relationship with the client is in the working phase;
1.The client attempts to familiarize himself with the nurse.
2.The client makes an effort to describe his problems in detail
3.The client tries to summarize his progress in the relationship.
4.The client starts to challenge the boundaries or outer limits of the relationship.
(The answer is 2.This nurse-client relationship is most probably in the working phase. The client's effort to describe his problem to the nurse illustrates that the client has gone beyond testing and acquainting him self with a new relationship and is now working on his problems. The relationship is in an orientation phase when the client attempt to familiarize him self with the nurse and challenges boundaries of the relationship. The relationship is in a termination phase when the client summarizes and evaluates his progress).
8. The client is concerned that the information he gives to the nurse remains confidential .Which of the following comments would be best for the nurse to make in this situation;
1."if the information you share with me is important in relation to your care,I'll need to share it with the staff"
2."we can keep the information just between the two of us if you prefer"
3."I'll share the information with staff members only with your approval"
4."you can decide whether your physician needs this information for your care"
(The answer is 1.The nurse should make sure that the client understands that the nurse's need to discus information given by the client when,in the nurse's judgment, the information is necessary in relation to his therapy. This is a judgment the client is unable to make with safety. Promising a client to keep information confidential places the nurse in a difficult position. If the client tells the nurse something that the nurse consider vital information for others on the health team, the nurse would need to break a promise to the client to share the information).
A Client is admitted to the psychiatric unit with complains of sleep disturbance, fatigue, feeling of uselessness, and inability to concentrate. The client was let go from her place of employment last month owing to her inability to keep up with demands of her position.
9.On the day after an interview during which the client talked at length and tearfully about feeling useless and old, she failed to keep an appointment with the nurse.Which action would be best for the nurse to take.
1.Assume that the client had a good reason for not coming and let her make for fro next move.
2.Confront the client with her behavior and ask her to explain the reason fro her absence.
3.Seek out the client at the end of the scheduled interview time and tell her she was missed to day.
4.Arrange for another session with the later the same day and say nothing about her absence .
( 3.The responsibility for maintaining a relationship with a client rest with the nurse.If a client missed a scheduled interview,the nurse is assuming responsibility fro the relationship by seeking her out at the end of the scheduled interview time and telling her she was missed. To confront the client with her absence and ask her to explain it is non therapeutic and threatening. To arrange another session with the client and to say nothing about the missed appointment does not keep to the terms of the nurse-client contract and offers little help to the client. The nurse make an assumption with out knowing the facts by thinking that the patient has good reason for not keeping her appointment. The nurse is not assuming responsibility by waiting fro the client to make the next move in this situation).
10.The client speaks in the a seemingly sincere manner about her former employer who replace her with a younger person ."he was a wonderful boss.He was most understanding boss I've ever had . It was a privilege to work fro him.". Which of the following defense mechanisms is the client most likely using.
1.Sublimation.
2.Suppression.
3.Repression.
4.Reaction formation.
(The answer is 4. Reaction formation is a defense mechanism that occurs when a person expresses an attitude or feeling opposite from the unconscious feelings or attitudes. The client compliments her employer when unconsciously, she most likely does not like him because he fired her. Sublimation involves directing unacceptable impulses into constructive channels. Suppression is a conscious effort to overcome unacceptable thoughts or desires. Repression is a defense mechanism that occur when a person excludes or bars painful experiences and thoughts from his or her state of consciousness).
11.The client begins to attend group sessions daily. she explains to her group how she lost her job.Which of the following statements by a group members would be most therapeutic for the client;
1."Tell us about what you did on your job"
2."It must have been very upsetting for you"
3."With you skills,finding another job should be easy"
4."The company must have had some reason fro letting you go"
(The answer is 2. It is most therapeutic when client is in group sessions help each other explore feeling furthers and when they demonstrate understanding of each other.In this situation, asking the client to describe her work and indicating that the company must have had a reason for firing her avoid discussing the client's feelings. Suggesting to the client that she will have no trouble finding another job offers false hope without full knowledge of the situation).
12. During an interaction with the nurse, the client state,"I have nothing to be depressed about my husband has supported me throughout each of my many hospitalizations.He'll probably leave me this time. I am an awful person and wife. I'm no good I can't do anything right." Based on this information the nurse should consider which of the following as an appropriate nursing diagnosis;
1.Ineffective individual coping related to depression,as evidence by withdrawal.
2.Self Esteem disturbance related to numerous hospitalization, as evidence by negative self statements.
3.Dysfunction Grieving related to imagined loss of husband, as evidence by negativity.
4.Potential for Self-Directed Violence related to numerous failures,as evidence by worthlessness.
(The answer is 2. Negative self- statement are directly related to how the client view and feels about her self. The comment reflex a feeling of low self-esteem because of the psychopathology of the illness necessitating or related to her many hospitalizations. The negative view of self is a prominent theme underlying her verbalization.Information concerning whether the client is withdrawal or is going to hurt herself is absent. The client only imagines that her husband will leave her because of her view of herself).
13.The client has tearfully described her negative feelings about her self to the nurse during their last three interactions.Which of the following goals would be most appropriate for the nurse to include in the care plan at this time; The client will:
1.increase her self-esteem.
2.write her negative feelings in a daily journal.
3.verbalize her work-related accomplishments.
4.verbalize three things she likes about herself.
The Answer is 4. Describing and verbalizing feeling are necessary and normal because the client has usually repressed or blocked feelings, which is partly responsible for the client's pain.Expressing feeling are a pre requisite before the nurse can intervene in how the client thinks or behaves.Stating a goal like increasing self esteem is too global and non specific. Writing feeling in a journal will not benefit the client since she has verbalized them to the nurse. Verbalizing work related accomplishments is too specific and focuses on only one client aspect. Focusing on what the client likes about herself is too broad for what the client thinks is important to her. Asking the client to identify only three qualities does not overwhelm the client.
The client with depression has been hospitalized for 3 days on the psychiatric unit.This is the second hospitalization during the past year.
14. The physician orders a different drug,tranylcypromine sulfat(Parnate),when the client does not respond positively to a trycyclic anti depressant. Which of the following reaction should be client be cautioned about if her diet included foods containing;
1.Heart block
2.Grand mal seizure.
3.Respiratory arrest.
4.Hypertensive crisis.
(The answer is 4.Tranylcypromine sulfate(parnate) is a monoamine oxidase (MAO) inhibitor. A client taking this drug in combination with foods or beverages rich in tyramine is likely to have hypertensive crisis. The medication should be discontinued and the physician notified if he client exhibits symptoms related to an impending hypertensive crisis,such as headaches,diaphoresis,palpitations,pallor,nausea and vomiting,and chest pain).
15. While the client is taking tranylcypromine sulfate (parnate), the nurse would teach her to avoid which food in particular because of its high tyramine content;
1.Nuts.
2.Aged cheeses.
3.Grain cereals.
4.Reconstituted milk.
(The answer is 2. Aged and strong cheeses are tyramine rich foods and,when ingested in combination with MAO inhibitors, can cause a sever hypertensive crisis. Other foods and beverages rich in tyramine include aged meat and other non fresh meat,liver,dried fish, any fermented high-protein food(eg,yeast extracts and concentrates), Italian broad beans (pods), green bean pods, wine, beer,and ale. In many instances, the following caffeine-containing soft drinks).
16. The client obtains permission for 24-hour pass to go home. Which of the following suggestions to the family in preparing for the visit indicates the best understanding of the client's needs;
1.Plan to encourage the client to seek employment outside the home.
2.Limit friends visit so that the client can rest during the day.
3.Schedule a day of interesting activities for the client outside the home.
4.Plan to involve the client in usual at-home pursuits of the immediate family.
(The answer is 4.Planing to involve the client in usual at-home pursuits of the immediate family is the best when the client is to go home for a pass. There are no indications that this client requires extra rest or unusual activities. It is too early, and possibly inappropriate,for the client to start looking for employment).
17.After a 2-month hospitalization , the client is preparing for discharge. Which of the following subjects would be most helpful to discuss when preparing to terminate the nurse-client relationship;
1.The gains that the client has made during therapy.
2.The plans that the client should make to find a job.
3.The knowledge that the client's daughter is divorcing her husband.
4.The conflict the client has had with another staff member.
(The answer is 1.Terminating a nurse-client relationship is a weaning process.Subject such as plans for finding employment,divorce plans of a family member,and conflict during hospitalization do not aid this weaning.Discussing the gains that the client has made during hospitalization does.The content focuses on gain made in treatment, feelings about termination and saying goodbye. Introducing new material at termination may impede therapeutic termination).
18.Which client reaction in terminating the relationship wit the nurse should be considered the most healthy;
1.A lack a respond.
2.A display of anger.
3.An attempt at humor
4.An expression of grief.
(4. Grief is a direct and appropriate responds to termination of a positive relation and indicates acceptance of termination.Anger is healthy when openly expressed but is a less healthy reaction than grief. A lack of response may be interpreted indifference, but it represents a profound emotional reaction that the patient is unable to express. Humor may be a defense against feeling of loss).
A Client is admitted involuntarily by court order to a psychiatric hospital for 90 days.Document sent with her cite,among other things, that she will not eat because she feels her stomach is missing and her bowels have turned to jelly,and that she views this as"just punishment for my past wickedness and for the evil I've brought on my family"
19.To be valuated as being legally committable,Which of the following criteria did the client most likely have to meet;
1.Presence of psychosis.
2.Tried to harm herself or others.
3.Unable to afford private treatment.
4.Made threatening remark to friends of relatives.
(The answer is 2. client is legally committable when she tires to harm herself or others)
.
20.Which of the following right did the client lose by being admitted involuntarily to a psychiatric hospital, The right to;
1.send and receive mail.
2.vote in a national election.
3.make a will or legally binding contract.
4.sign out of the hospital against medical advice.
(The answer is 4. person who has been involuntarily committed to a hospital for the mentally ill loses the right to leave the hospital of his own accord. He does not necessary loses right to vote, make a will or contract, or send and receive mail).
21.Through which of the following legal methods could the client seek release from the psychiatric hospital if she believed she was being improperly detained;
1.Malpractice suit
2.Guardianship hearing
3.Writ of habeas corpus.
4.Lien of property petition
(3. A write of habeas corpus is defined as an order requiring that a prisoner (in this case,the client) be brought before a judge or into court to decide whether he is being held lawfully. Its purpose is to obtain liberation of a person held with out just cause).
22.When the expresses feeling of unworthiness, how would the nurse best respond;
1."Your family love you even if you feel unworthy".
2."Your feeling of being unworthy are just your imagination"
3."It would be best to try to forget the idea that you are unworthy"
4."As you begin to feel better, your feelings of unworthiness will begin to disappear".
(The answer is 4. When the client feel unworthiness, she reflects low self-esteem. Presenting another set of facts in a manner that is accepting of the client but avoids a power struggle is necessary. Telling the client that her feelings are imaginary, that her family still loves her,and that she should try to forget ideas of unworthiness disregard her feeling and may be perceived as rejection).
23.The has not been eating after serving the client her tray,which of the following actions by the nurse would be most likely to encourage her to eat;
1.Leave the client's room with out comment.
2.Sit beside the client and place the fork in her hand.
3.Tell the client that she will not recover unless she eats.
4.Comment on how good the food looks.
(2. sitting beside the client and placing the fork in her hand are likely to stimulate the depressed client to eat. Sitting with the client also conveys message of having time for her and of caring. Leaving the client alone, telling her that she must eat to recover, and trying to encourage her by saying the food looks good are techniques that are likely to interest the client in eating).
24.The nurse notes that the client becomes restless and incoherent at night. Besides administering a prescribed medication,which of the following actions by the nurse would be most helpful for the client at this time;
1.Encouraged the client to talk about her family.
2.Read to the client with the lights turned down low.
3.Help the client take a cool shower before retiring.
4.Sit quietly with the client until the medication takes effect.
( The answer is 4. doing something with or to this client is unlikely to help restlessness and incoherence. It is best to sit quietly with the client until the medication takes effect. A warm bath might be helpful, but not a cool shower).
25.The client demand to be left alone to die.She states,"If you try to cheat he avenger, you will suffer."
Which of the following possible replies by the nurse would be best;
1."I won't let anything harm you"
2."It sounds like you're trying to frighten me."
3."I'm not trying to cheat anyone. What do you mean by that".
4."I'll leave you alone for 15 minutes.Then I'll be back to see how you're doing".
( 4. When this client wants to be left alone to die, it best to leave the client for a few minutes, then return to see how the client is getting along. This response acknowledges the client's request and also lets the client know that the nurse will be back shortly. It responds to reality. Telling the client that the nurse will not allow anything to hurt the client, that the nurse is not trying to frighten the nurse all are responding to delusional material).
