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A client is admitted for major depression. What should the nurse expect to find during assessment?
- A. Anhedonia, feelings of worthlessness, and difficulty focusing
- B. Depressed mood, guilt, and pressured speech
- C. Changes in sleep pattern, tired, and grandiose mood
- D. Difficulty focusing, feelings of helplessness, and flight of ideas
Correct Answer: A
Rationale: Major depression typically presents with anhedonia, worthlessness, and difficulty focusing, unlike symptoms of mania.
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Which client is at highest risk for carrying out a suicide plan?
- A. A client who plans to take a bottle of sleeping pills.
- B. A client who says, 'My life is over.'
- C. A client who has a private gun collection.
- D. A client who says, 'I'm going to jump off the next bridge I see.'
Correct Answer: C
Rationale: Access to a lethal means like a gun collection significantly increases the likelihood of completing a suicide plan.
Which best explains the neurochemical processes responsible for depression?
- A. Increased activity of dopamine
- B. Decreased glucocorticoid activity
- C. Decreased serotonin and norepinephrine
- D. Potentiation of GABA
Correct Answer: C
Rationale: Decreased levels of serotonin and norepinephrine in the brain are associated with depression, contributing to mood dysregulation.
A client who is manic states, 'What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?' Which would be the most appropriate response by the nurse?
- A. Please slow down. I'm not sure what you need first.
- B. You will have to be quiet and have breakfast after the doctor comes.
- C. Are you hungry?
- D. Your thoughts seem to be racing this morning.
Correct Answer: A
Rationale: Asking the client to slow down facilitates communication without blaming, addressing their pressured speech.
Which is a possible explanation for the increased risk of suicide in persons who have had a relative who committed suicide?
- A. The relative's suicide offers a sense of permission or acceptance of suicide as a method of escaping a difficult situation.
- B. Many people with depression who have suicidal ideation lack the energy to implement suicide plans, but antidepressant treatment can actually give clients with depression the energy to act on suicidal ideation.
- C. Suicide is more likely to occur in April when natural energy from increased sunlight may give the client the energy to act on suicidal ideation.
- D. The relative's suicide caused the family members to realize that suicide is emotionally harmful to the ones left behind and vow not to consider suicide.
Correct Answer: A
Rationale: A relative's suicide may normalize the act, increasing risk by providing a sense of acceptability.
A client who is depressed states, 'I think my family would be better off without me. They don't need to worry.' Which would be the most appropriate response by the nurse?
- A. Are you planning to commit suicide?
- B. What do you think they are worried about?
- C. You don't mean that. Your family loves you.
Correct Answer: A
Rationale: Directly asking about suicidal plans addresses potential ideation, ensuring safety and opening further assessment.