Nokea
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.
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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 beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food?
- A. Tomato juice
- B. Orange juice
- C. Hot tea
- D. Milk
Correct Answer: D
Rationale: Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.
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 student nurse caring for a patient diagnosed with major depressive disorder reads in the patient's medical record, 'This patient shows vegetative signs of depression.' Which nursing diagnoses most clearly relate to the vegetative signs?
- A. Imbalanced nutrition: less than body requirements
- B. Chronic low self-esteem
- C. Sexual dysfunction
- D. Self-care deficit
- E. Powerlessness
- F. Insomnia
Correct Answer: A,C,D,F
Rationale: Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self.
An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?
- A. Social skills training
- B. Relaxation training classes
- C. Use of complementary therapy
- D. Learning desensitization techniques
Correct Answer: A
Rationale: Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patient's support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias.