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A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take?
- A. Reinforce how to use assertive communication techniques.
- B. Schedule the client's daily self-care activities.
- C. Discourage the client from expressing anger.
- D. Set short-term and long-term goals for the client.
Correct Answer: D
Rationale: Assertiveness is secondary to overall planning. Scheduling self-care helps but isn’t comprehensive. Suppressing anger hinders emotional health. Goal setting provides direction and motivation, key to depression management.
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An older adult is given the diagnosis of depression and is started on medication. Which group of medications would be appropriate for the depressed older adult?
- A. Selective serotonin reuptake inhibitors (SSRIs)
- B. Benzodiazepines
- C. Hypnotics
- D. Monoamine oxidase inhibitors
Correct Answer: A
Rationale: SSRIs are often the first-line treatment for depression in older adults due to their favorable side effect profile, including lower risk of sedation and falls compared to other options. Benzodiazepines are not typically used for depression as they treat anxiety and can increase the risk of falls and confusion in older adults. Hypnotics are used for sleep issues, not as antidepressants, and don’t address the core symptoms of depression. Monoamine oxidase inhibitors are effective but often reserved for cases where other treatments fail due to their dietary restrictions and potential for serious side effects.
A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and, based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?
- A. Check the bruises at the next visit to the client's home.
- B. Institute more frequent visits to the client's home.
- C. Follow the agency's guidelines for reporting suspected abuse.
- D. Arrange referral for family therapy to deal with home stressors.
Correct Answer: C
Rationale: Delaying action by checking bruises later doesn’t address immediate safety. More frequent visits monitor but don’t act on the suspicion promptly. Following agency guidelines for reporting suspected abuse ensures the client’s safety first, as it’s the nurse’s legal and ethical duty. Therapy may help later but isn’t the first step without ensuring safety.
In developing a nursing care plan for an adult with a mental health disorder, the nurse knows the goals that are set must be:
- A. Important to the client
- B. Evaluated on a weekly basis
- C. Achievable by client discharge
- D. Approved by the physician
Correct Answer: A
Rationale: Client-important goals boost engagement. Weekly evaluation is useful but not mandatory. Discharge-tied goals may not fit long-term needs. Physician approval is secondary to client-centered planning.
A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?
- A. If you do not get out of bed, you will not receive your meal.'
- B. You really need to follow the rules of the unit and get out of bed.'
- C. I will help you sit up and get your slippers on.'
- D. You should rest in bed until you feel able to take part in unit activities.'
Correct Answer: C
Rationale: Threatening to withhold meals is coercive. Enforcing rules dismisses the client’s fatigue. Offering help supports the client’s engagement without pressure, addressing depression’s lethargy. Encouraging rest may reinforce withdrawal, worsening depression.
A nurse is caring for a client who has an anxiety disorder. Which of the following findings should the nurse recognize as a manifestation of mild anxiety?
- A. Incoherent speech
- B. Irritability
- C. Insomnia
- D. Chest pain
Correct Answer: B
Rationale: Incoherent speech indicates severe anxiety. Irritability is a mild anxiety sign, with maintained function. Insomnia suggests chronic anxiety. Chest pain aligns with severe anxiety or panic.