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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.
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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.
Which variables represent the highest risk for developing major depressive disorder? Select all that apply.
- A. Male gender
- B. Mood disorder in first-degree relatives
- C. Substance abuse
- D. Divorced
- E. Older adult
Correct Answer: B,D
Rationale: Family history of mood disorders and being single or divorced increase the risk of major depressive disorder.
The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
- A. The client will avoid causing harm to others.
- B. The client will be free from stress.
- C. The client will independently carry out activities of daily living.
- D. The client will not experience agitation.
Correct Answer: C
Rationale: Independently performing activities of daily living is a realistic and appropriate outcome for a client with depression.
Which is a Freudian explanation of the etiology of depression?
- A. Depression is a reaction to a distressing life experience.
- B. Depression results from being raised by rejecting or unloving parents.
- C. Depression results from cognitive distortions.
- D. Depression is anger turned inward.
Correct Answer: D
Rationale: Freud's theory posits that depression arises from internalized anger due to real or perceived loss, leading to self-reproach.
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.