Nokea
A patient diagnosed with major depressive disorder repeatedly tells staff members, 'I have cancer. It's my punishment for being a bad person.' Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
- A. Powerlessness
- B. Risk for suicide
- C. Stress overload
- D. Spiritual distress
Correct Answer: B
Rationale: A patient with depression who feels so worthless as to believe cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses listed.
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A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, 'I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up.' The nurse should implement what intervention?
- A. Explain how to manage postural hypotension and educate the patient that side effects go away after several weeks.
- B. Tell the patient that the side effects are a minor inconvenience compared with the feelings of depression.
- C. Withhold the drug, force oral fluids, and notify the health care provider to examine the patient.
- D. Teach the patient how to use pursed-lip breathing.
Correct Answer: A
Rationale: Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Pursed-lip breathing is irrelevant.
During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, 'Life feels so hopeless to me. I've been feeling sad for several months.' How should the nurse document the patient's affect and mood?
- A. Affect depressed; mood flat
- B. Affect flat; mood depressed
- C. Affect labile; mood euphoric
- D. Affect and mood are incongruent
Correct Answer: B
Rationale: Mood is a person's self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.
A patient says to the nurse, 'My life does not have any happiness in it anymore. I once enjoyed holidays, but now they're just another day.' How would the nurse document the patient's statement?
- A. Vegetative
- B. Anhedonia
- C. Euphoria
- D. Anergia
Correct Answer: B
Rationale: Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Vegetative symptoms refer to somatic changes associated with depression. Euphoria refers to an elated mood. Anergia means without energy.
What is a priority nursing intervention for a patient diagnosed with major depressive disorder?
- A. Distracting the patient from self-absorption
- B. Carefully and inconspicuously observing the patient around the clock
- C. Allowing the patient to spend long periods alone in self-reflection
- D. Offering opportunities for the patient to assume a leadership role in the therapeutic milieu
Correct Answer: B
Rationale: Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regularly planned observations of the patient with depression may prevent a suicide attempt on the unit.
What is the focus of priority nursing care for the period immediately after a patient has an electroconvulsive therapy (ECT) treatment?
- A. Supporting physiological stability
- B. Reducing disorientation and confusion
- C. Monitoring pupillary responses
- D. Assisting the patient to plan for the future
Correct Answer: A
Rationale: During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiological stability. Monitoring pupillary responses is not a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient to plan for the future is inappropriate in the immediate post-treatment period because the patient may be confused.