Nokea
A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, 'No one cares about me anymore. I'm not worth anything.' Select an appropriate initial outcome.
- A. The patient will verbalize realistic positive characteristics about self by (date).
- B. The patient will consent to take antidepressant medication regularly by (date).
- C. The patient will initiate social interaction with another person daily by (date).
- D. The patient will identify two personal behaviors that alienate others by (date).
Correct Answer: A
Rationale: Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.
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A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, 'I feel like a failure. This baby is the root of my problems.' What is the priority nursing diagnosis?
- A. Insomnia
- B. Ineffective coping
- C. Situational low self-esteem
- D. Risk for other-directed violence
Correct Answer: D
Rationale: When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.
A nurse provided medication education for a patient who is prescribed phenelzine for depression. Which patient behavior indicates effective learning?
- A. Monitors sodium intake and weight daily.
- B. Wears support stockings and elevates the legs when sitting.
- C. Consults the pharmacist when selecting over-the-counter medications.
- D. Can identify foods with high selenium content, which should be avoided.
Correct Answer: C
Rationale: Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.
A patient was started on escitalopram 5 days ago and now says, 'This medicine isn't working.' What is the nurse's best intervention?
- A. Discussing with the health care provider the need to change medications
- B. Reassuring the patient that the medication will be effective soon
- C. Explaining the time lag before antidepressants relieve symptoms
- D. Critically assessing the patient for symptom relief
Correct Answer: C
Rationale: Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are usually necessary before a relief of symptoms occurs. This information is important to share with patients.
Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?
- A. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
- B. Slept 10 hours uninterrupted. Attended craft group; stated 'project was a failure, just like me.'
- C. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.
- D. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, 'I feel tired all the time.'
Correct Answer: A
Rationale: Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding.
A patient diagnosed with major depressive disorder tells the nurse, 'Bad things that happen are always my fault.' To assist the patient in reframing this overgeneralization, how should the nurse respond?
- A. I really doubt that one person can be blamed for all the bad things that happen.
- B. Let's look at one bad thing that happened to see if another explanation exists.
- C. You are being exceptionally hard on yourself when you say those things.
- D. How does your belief in fate relate to your cultural heritage?
Correct Answer: B
Rationale: By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses are judgmental, irrelevant to an overgeneralization, and cast doubt without requiring the patient to evaluate the statement.