Nokea
The nurse is planning care for a client with major depression. Which is an appropriate expected outcome?
- A. The client will avoid causing harm to others.
- B. The client will be free from stress.
- C. The client will independently carry out activities of daily living.
- D. The client will not experience agitation.
Correct Answer: C
Rationale: Independently performing activities of daily living is a realistic and appropriate outcome for a client with depression.
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A client who is depressed begins to cry and states, 'I'm just really sick of feeling this way. Nothing ever seems to go right in my life.' Which would be the most appropriate response by the nurse?
- A. Don't cry. Try to look at the positive side of things.
- B. You are feeling really sad right now. It's a hard time.
- C. Hang in there. Your medication will start helping in a few days.
- D. Nothing ever goes right?
Correct Answer: B
Rationale: Acknowledging the client's sadness validates their feelings, fostering a therapeutic connection without dismissing emotions.
A client who is depressed states, 'I think my family would be better off without me. They don't need to worry.' Which would be the most appropriate response by the nurse?
- A. Are you planning to commit suicide?
- B. What do you think they are worried about?
- C. You don't mean that. Your family loves you.
Correct Answer: A
Rationale: Directly asking about suicidal plans addresses potential ideation, ensuring safety and opening further assessment.
Which time periods during antidepressant therapy are persons most likely to commit suicide? Select all that apply.
- A. After starting antidepressant therapy but not having reached the therapeutic level
- B. After having reached the therapeutic level of antidepressants and maintained it for several years
- C. If the client has made a choice to discontinue antidepressant therapy without medical supervision and is becoming gradually more depressed
- D. If the client does not adhere to the medication regimen and takes antidepressant medications irregularly
- E. Prior to initiating antidepressant therapy but before the depression results in lack of energy
Correct Answer: A,C,D,E
Rationale: Suicide risk is highest when energy increases before mood stabilizes, or during untreated or poorly managed depression.
The wife of a client with bipolar disorder calls the nurse expressing distress about recent spending. The nurse's action would be considered
- A. inappropriate; the nurse should not give advice to the wife.
- B. inappropriate; the husband has the legal right to spend personal money.
- C. appropriate; the wife is responsible for the husband's actions since he has a mental illness.
- D. appropriate; the wife needs support in setting boundaries.
Correct Answer: D
Rationale: Supporting the wife in setting boundaries is appropriate, as it empowers her to manage the client's manic behavior.
A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?
- A. Administering a sedative that has been prescribed to be used PRN.
- B. Insisting the client take a time-out in his room.
- C. Clearing the area of all other clients.
- D. Setting limits on aggressive and intimidating behavior.
Correct Answer: D
Rationale: Setting limits on aggressive behavior is the initial action to ensure safety while allowing the client to exercise self-control.