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Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?
- A. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
- B. Slept 10 hours uninterrupted. Attended craft group; stated 'project was a failure, just like me.'
- C. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.
- D. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, 'I feel tired all the time.'
Correct Answer: A
Rationale: Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding.
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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.
A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, 'I feel like a failure. This baby is the root of my problems.' What is the priority nursing diagnosis?
- A. Insomnia
- B. Ineffective coping
- C. Situational low self-esteem
- D. Risk for other-directed violence
Correct Answer: D
Rationale: When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.
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.
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.
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.