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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.
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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.
A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?
- A. Avoid exposure to bright sunlight.
- B. Report increased suicidal thoughts.
- C. Restrict sodium intake to 1 g daily.
- D. Maintain a tyramine-free diet.
Correct Answer: B
Rationale: Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?
- A. Dry mouth
- B. Blurred vision
- C. Nasal congestion
- D. Urinary retention
Correct Answer: D
Rationale: All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.
A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
- A. Mashed potatoes, ground beef patty, corn, green beans, apple pie
- B. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
- C. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
- D. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
Correct Answer: A
Rationale: The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.
A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment?
- A. Administer pretreatment medication 30 to 45 minutes before treatment.
- B. Withhold food and fluids for a minimum of 6 hours before treatment.
- C. Remove dentures, glasses, contact lenses, and hearing aids.
- D. Restrain the patient in bed with padded limb restraints.
- E. Assist the patient to prepare an advance directive.
Correct Answer: A,B,C
Rationale: The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment.