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When a patient is diagnosed with major depressive disorder, which nursing diagnosis should be the priority?
- A. Imbalanced nutrition: less than body requirements
- B. Risk for suicide
- C. Disturbed sleep pattern
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for suicide. This is the priority nursing diagnosis because individuals with major depressive disorder have an increased risk of suicidal ideation and behaviors. Assessing and addressing this risk is crucial for patient safety. Choice A is not the priority as nutritional imbalances may not pose immediate harm compared to suicide risk. Choice C, disturbed sleep pattern, and choice D, ineffective coping, are important but not as critical as addressing the risk of suicide in a patient with major depressive disorder.
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A patient with posttraumatic stress disorder (PTSD) is experiencing flashbacks. What is the best initial intervention?
- A. Encouraging the patient to avoid triggers
- B. Encouraging the patient to talk about their feelings
- C. Providing the patient with relaxation techniques
- D. Advising the patient to avoid social situations
Correct Answer: C
Rationale: The correct initial intervention for a patient with PTSD experiencing flashbacks is providing relaxation techniques (Choice C). This is because relaxation techniques can help the patient cope with the distressing symptoms and manage their anxiety levels during flashbacks. Encouraging the patient to avoid triggers (Choice A) may provide temporary relief but does not address the root cause of the flashbacks. Encouraging the patient to talk about their feelings (Choice B) may be beneficial in the long run but may not be the best initial intervention during a flashback. Advising the patient to avoid social situations (Choice D) can lead to isolation and may not address the immediate distress caused by the flashbacks.
When assessing a patient with major depressive disorder, which of the following is a common cognitive symptom?
- A. Hallucinations
- B. Delusions
- C. Lack of appetite
- D. Negative self-talk
Correct Answer: D
Rationale: The correct answer is D: Negative self-talk. In major depressive disorder, negative self-talk is a common cognitive symptom known as cognitive distortions. This includes thoughts of worthlessness, guilt, or self-criticism. This symptom is a key aspect of the cognitive triad in depression. Hallucinations and delusions are more indicative of psychotic disorders, while lack of appetite is a physical symptom commonly seen in depression but not a cognitive symptom. In summary, negative self-talk is the correct answer as it directly relates to the cognitive distortions commonly seen in major depressive disorder.
Which of the following is a positive symptom of schizophrenia?
- A. Apathy
- B. Social withdrawal
- C. Delusions
- D. Flat affect
Correct Answer: C
Rationale: The correct answer is C: Delusions. Positive symptoms of schizophrenia are behaviors or experiences that are added to a person's normal repertoire of functioning. Delusions are a hallmark positive symptom of schizophrenia, characterized by fixed false beliefs that are not based in reality. Apathy (choice A) and social withdrawal (choice B) are negative symptoms, which involve a reduction or absence of normal behaviors. Flat affect (choice D) is also a negative symptom, referring to a lack of emotional expressiveness. In summary, delusions are the correct choice as they represent a positive symptom of schizophrenia, while the other choices are negative symptoms.
A patient with major depressive disorder is started on fluoxetine. What is a common side effect the nurse should monitor for?
- A. Weight gain
- B. Increased appetite
- C. Nausea
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Nausea. Fluoxetine, an SSRI antidepressant, commonly causes gastrointestinal side effects such as nausea. This is due to its effect on serotonin levels in the gut. Weight gain (A) and increased appetite (B) are less common side effects of fluoxetine. Dry mouth (D) is more commonly associated with tricyclic antidepressants, not SSRIs. Monitoring for nausea is crucial to ensure patient compliance and well-being.
In cognitive processing therapy for PTSD, what is the primary goal for the patient?
- A. To help the patient process the trauma and reduce avoidance behaviors.
- B. To help the patient confront and process the trauma in a safe environment.
- C. To help the patient understand the impact of the trauma on their current thoughts and behaviors.
- D. To help the patient avoid triggers that remind them of the trauma.
Correct Answer: C
Rationale: The correct answer is C because the primary goal of cognitive processing therapy in PTSD is to help the patient understand the impact of trauma on their current thoughts and behaviors. This involves identifying and challenging maladaptive beliefs and cognitive distortions related to the trauma. By gaining insight into how the trauma has influenced their thoughts and behaviors, the patient can work towards changing these patterns and improving their psychological well-being.
Choice A is incorrect because while processing the trauma and reducing avoidance behaviors are important aspects of therapy, they are not the primary goal in cognitive processing therapy. Choice B is incorrect as it focuses solely on confronting and processing the trauma, missing the crucial component of understanding its impact on thoughts and behaviors. Choice D is incorrect because avoidance of triggers is not the primary goal; rather, it is about addressing and modifying the cognitive responses to those triggers.