Nokea
A client with depression is experiencing anhedonia. Which statement by the client reflects this symptom?
- A. I feel so anxious all the time.
- B. I don't enjoy the things I used to love.
- C. I can't concentrate on anything.
- D. I have trouble sleeping through the night.
Correct Answer: B
Rationale: Anhedonia is the inability to experience pleasure from activities usually found enjoyable. The statement 'I don't enjoy the things I used to love' directly reflects this symptom as the client is expressing a lack of pleasure from previously enjoyable activities. Choices A, C, and D do not specifically relate to anhedonia but rather indicate symptoms of anxiety, concentration difficulties, and sleep disturbances, respectively.
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After a client with major depressive disorder undergoes electroconvulsive therapy (ECT), which of the following is a priority assessment for the nurse?
- A. Monitoring for signs of infection
- B. Monitoring for signs of respiratory distress
- C. Monitoring for signs of hypotension
- D. Monitoring for signs of bleeding
Correct Answer: B
Rationale: The priority assessment for the nurse after a client undergoes electroconvulsive therapy (ECT) is monitoring for signs of respiratory distress. This is crucial due to the potential risk of complications from anesthesia, such as airway compromise or respiratory depression. Prompt identification and intervention in case of respiratory distress are essential to ensure the client's safety and well-being. Monitoring for signs of infection (Choice A) is important but not the priority immediately post-ECT. Hypotension (Choice C) and bleeding (Choice D) are also potential concerns but assessing respiratory distress takes precedence due to the immediate risk it poses to the client's well-being.
Which client action is an example of the defense mechanism of reaction formation?
- A. A woman who feels unattractive constantly praises the looks of others.
- B. A man who feels insecure about his masculinity exaggerates his strength.
- C. A person who feels guilty about cheating accuses others of being unfaithful.
- D. A child who feels neglected tries to win approval from teachers.
Correct Answer: A
Rationale: The defense mechanism of reaction formation involves expressing the opposite of one's true feelings. In this case, the woman who feels unattractive praises the looks of others as a way to mask her own feelings of inadequacy. This behavior represents a form of overcompensation where the individual showcases an exaggerated opposite trait to conceal their true emotions. Choices B, C, and D do not align with reaction formation. Choice B describes compensation, where one overemphasizes a trait to make up for a perceived weakness. Choice C illustrates projection, where one attributes their feelings onto others. Choice D demonstrates a form of seeking attention or approval, which does not fit reaction formation.
A client has been diagnosed with major depressive disorder. Which is an appropriate short-term goal for the client?
- A. The client will report a decrease in depressive symptoms.
- B. The client will establish a sleep routine.
- C. The client will improve social interactions.
- D. The client will set realistic goals for the future.
Correct Answer: A
Rationale: Setting a goal for the client to report a decrease in depressive symptoms is appropriate as it is specific, measurable, and achievable in the short term. Monitoring changes in depressive symptoms provides valuable feedback on the effectiveness of the treatment plan. While establishing a sleep routine, improving social interactions, and setting realistic goals for the future are important aspects of recovery, they are more suitable as intermediate or long-term goals. In the context of short-term goals, focusing on symptom reduction can provide immediate feedback on the client's progress and help adjust the treatment plan accordingly.
A client has been prescribed bupropion (Wellbutrin) for depression. Which instruction should the nurse provide during discharge?
- A. Take the medication with a full glass of water.
- B. Stop taking the medication if you feel better.
- C. Avoid drinking alcohol while taking this medication.
- D. Double the dose if you miss a dose.
Correct Answer: C
Rationale: The correct instruction for the nurse to provide is to advise the client to avoid drinking alcohol while taking bupropion (Wellbutrin) due to the increased risk of side effects like seizures. Alcohol can interact with bupropion and worsen its side effects, making it important to abstain from alcohol consumption during the treatment. Option A is incorrect because taking the medication with a full glass of water is a general instruction for medications and not specific to bupropion. Option B is incorrect as abruptly stopping bupropion can lead to withdrawal symptoms and should only be done under medical supervision. Option D is incorrect as doubling the dose of bupropion is dangerous and should not be done, even if a dose is missed.
When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?
- A. Restlessness
- B. Rapid heart rate
- C. Sweating
- D. Dry mouth
Correct Answer: B
Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.