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Flashcards in Chapter 14 Deck (33):

1. A patient became severely depressed when the last of the family’s six children moved out of the home 4 months ago. The patient repeatedly says, “No one cares about me. I’m not worth anything.” Which response by the nurse would be the most helpful?
a. “Things will look brighter soon. Everyone feels down once in a while.”
b. “Our staff members care about you and want to try to help you get better.”
c. “It is difficult for others to care about you when you repeatedly say the same negative things.”
d. “I’ll sit with you for 10 minutes now and 10 minutes after lunch to help you feel that I care about you.”

Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a relationship with the nurse. The therapeutic technique is “offering self.” Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters trust building. The incorrect responses would be difficult for a person with profound depression to believe, provide false reassurance, and are counterproductive. The patient is unable to say positive things at this point.


2. A patient became depressed after the last of the family’s six children moved out of the home 4 months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment. The patient will:
a. verbalize realistic positive characteristics about self by (date).
b. agree to take an antidepressant medication regularly by (date).
c. initiate social interaction with another person daily by (date).
d. identify two personal behaviors that alienate others by (date).

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.


3. A patient diagnosed with major depression says, “No one cares about me anymore. I’m not worth anything.” Today the patient is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for this patient?
a. “You look nice this morning.”
b. “You’re wearing a new shirt.”
c. “I like the shirt you are wearing.”
d. “You must be feeling better today.”

Patients with depression usually see the negative side of things. The meaning of compliments may be altered to “I didn’t look nice yesterday” or “They didn’t like my other shirt.” Neutral comments such as making an observation avoid negative interpretations. Saying, “You look nice” or “I like your shirt” gives approval (non-therapeutic techniques). Saying “You must be feeling better today” is an assumption, which is non-therapeutic.


4. An adult diagnosed with major depression 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. Desensitization techniques
d. Use of complementary therapy

Social skill 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 development of a patient’s support system. Use of complementary therapy refers to adjunctive therapies such as herbals, which would be less helpful than social skill training. Assertiveness would be of greater value than relaxation training because passivity was a concern. Desensitization is used in treatment of phobias.


5. Priority interventions for a patient diagnosed with major depression and feelings of worthlessness should include:
a. distracting the patient from self-absorption.
b. careful unobtrusive observation around the clock.
c. allowing the patient to spend long periods alone in meditation.
d. opportunities to assume a leadership role in the therapeutic milieu.

Approximately two-thirds of people with depression contemplate suicide. Patients with depression who exhibit feelings of worthlessness are at higher risk. Regular planned observations of the patient diagnosed with depression may prevent a suicide attempt on the unit.


6. When counseling patients diagnosed with major depression, an advanced practice nurse will address the negative thought patterns by using:
a. psychoanalytic therapy.
b. desensitization therapy.
c. cognitive behavioral therapy.
d. alternative and complementary therapies.

Cognitive behavioral therapy attempts to alter the patient’s dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections between nerve cells in the brain and that it is at least as effective as medication. Evidence is not present to support superior outcomes for the other psychotherapeutic modalities mentioned.


7. A patient says to the nurse, “My life doesn’t have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” The nurse documents this report as an example of:
a. dysthymia. c. euphoria.
b. anhedonia. d. anergia.

Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an elated mood. Anergia means “without energy.”


8. A patient diagnosed with major depression began taking a tricyclic antidepressant 1 week ago. Today 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 will:
a. limit the patient’s activities to those that can be performed in a sitting position.
b. withhold the drug, force oral fluids, and notify the health care provider.
c. teach the patient strategies to manage postural hypotension.
d. update the patient’s mental status examination.

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 this information may convince the patient to continue the medication. Activity is an important aspect of the patient’s treatment plan and should not be limited to activities that can be done in a sitting position. Withholding the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions. Independent nursing action is called for. Updating a mental status examination is unnecessary.


9. A patient diagnosed with depression is receiving imipramine (Tofranil) 200 mg qhs. 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 c. Nasal congestion
b. Blurred vision d. Urinary retention

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.


10. A patient diagnosed with major depression tells the nurse, “Bad things that happen are always my fault.” Which response by the nurse will best assist the patient to reframe this overgeneralization?
a. “I really doubt that one person can be blamed for all the bad things that happen.”
b. “Let’s look at one bad thing that happened to see if another explanation exists.”
c. “You are being extremely hard on yourself. Try to have a positive focus.”
d. “Are you saying that you don’t have any good things happen?”

By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses cast doubt but do not require the patient to evaluate the statement.


11. A nurse worked with a patient diagnosed with major depression, severe withdrawal, and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at risk for feelings of:
a. guilt and despair. c. interest and pleasure.
b. over-involvement. d. ineffectiveness and frustration.

Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient’s progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with depression because of the patient’s resistance. Guilt and despair might be seen when the nurse experiences the patient’s feelings because of empathy. Interest is possible, but not the most likely result.


12. A patient diagnosed with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. The nurse should provide information to the patient and family about:
a. restricting sodium intake to 1 gram daily.
b. minimizing exposure to bright sunlight.
c. reporting increased suicidal thoughts.
d. maintaining a tyramine-free diet.

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.


13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse approve?
a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
b. Mashed potatoes, ground beef patty, corn, green beans, apple pie
c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.


14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment?
a. Nutrition and hydration
b. Supporting physiological stability
c. Reducing disorientation and confusion
d. Assisting the patient to identify and test negative thoughts

During the immediate post-treatment period, the patient is recovering from general anesthesia; hence, the priority need is to establish and support physiological stability. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.


15. A nurse provided medication education for a patient diagnosed with major depression who began a new prescription for phenelzine (Nardil). Which behavior indicates effective learning? The patient:
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. can identify foods with high selenium content that should be avoided.
d. confers with a pharmacist when selecting over-the-counter medications.

Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.


16. Major depression resulted after a patient’s employment was terminated. The patient now says to the nurse, “I’m not worth the time you spend with me. I am the most useless person in the world.” Which nursing diagnosis applies?
a. Powerlessness c. Situational low self-esteem
b. Defensive coping d. Disturbed personal identity

The patient’s statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to other diagnoses.


17. A patient diagnosed with major depression does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Which communication technique will be effective?
a. Make observations.
b. Ask the patient direct questions.
c. Phrase questions to require yes or no answers.
d. Frequently reassure the patient to reduce guilt feelings.

Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations for answers on the patient. Acceptance and support are shown by the nurse’s presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase feelings of worthlessness.


18. A patient being treated for depression has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, “I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares.” The nurse will advise the patient to:
a. “Go to the nearest emergency department immediately.”
b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.”
c. “Take a dose of your antidepressant now and come to the clinic to see the health care provider.”
d. “Resume taking your antidepressants for 2 more weeks and then discontinue them again.”

The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.


19. Which documentation for a patient diagnosed with major depression indicates the treatment plan 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.”

Sleeping 6 hours, participating with a group, and anticipating an event are all positive events. All the other options show at least one negative finding.


20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would this patient’s symptoms be most acute?
a. January c. June
b. April d. September

The days are short in January, so the patient would have the least exposure to sunlight. Seasonal affective disorder is associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.


21. A patient diagnosed with depression repeatedly tells staff, “I have cancer. It’s my punishment for being a bad person.” Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
a. Powerlessness c. Stress overload
b. Risk for suicide d. Spiritual distress

A patient diagnosed 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.


22. A patient diagnosed with major depression refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this patient?
a. Tomato juice c. Hot tea
b. Orange juice d. Milk

Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.


23. During a psychiatric assessment, the nurse observes a patient’s facial expression is without emotion. The patient says, “Life feels so hopeless to me. I’ve been feeling sad for several months.” How will 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.

Mood refers to a person’s self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others. When there is no evidence of emotion in a person’s expression, the affect is flat.


24. A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse will:
a. bring up the issue at the community meeting.
b. calmly tell the patient, “You must bathe daily.”
c. avoid forcing the issue in order to minimize stress.
d. firmly and neutrally assist the patient with showering.

When patients are unable to perform self-care activities, staff must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.


25. A patient diagnosed with major depression began taking escitalopram (Lexapro) 5 days ago. The patient now says, “This medicine isn’t working.” The nurse’s best intervention would be to:
a. discuss with the health care provider the need to increase the dose.
b. reassure the patient that the medication will be effective soon.
c. explain the time lag before antidepressants relieve symptoms.
d. critically assess the patient for symptoms of improvement.

Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary before symptom relief occurs. This information is important to share with patients.


26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate from this patient?
a. Arms crossed c. Smiling inappropriately
b. Staring at the nurse d. Eyes pointed downward

Nonverbal communication is usually considered more powerful than verbal communication. Downward casted eyes suggest feelings of worthlessness or hopelessness.


27. A patient diagnosed with major depression received six electroconvulsive therapy sessions and aggressive doses of antidepressant medication. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities.
b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet.
c. Temporary memory impairments and confusion may occur with electroconvulsive therapy.
d. The patient needs time to readjust to a pressured work schedule.

Recent memory impairment and/or confusion is often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten important details. The rationales are untrue statements in the incorrect responses. The patient needing time to reorient to a pressured work schedule is less relevant than the correct rationale.


28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:
a. hypotensive shock. c. cardiac dysrhythmia.
b. hypertensive crisis. d. cardiogenic shock.

Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels produces intense vasoconstriction, resulting in elevated blood pressure.


29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major depression. Which comment by the patient indicates teaching about the procedure was effective?
a. “They will put me to sleep during the procedure so I won’t know what is happening.”
b. “I might be a little dizzy or have a mild headache after each procedure.”
c. “I will be unable to care for my children for about 2 months.”
d. “I will avoid eating foods that contain tyramine.”

Transcranial Magnetic Stimulation (TCM) treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are awake and alert during the procedure. After the procedure, patients may experience a headache and lightheadedness. No neurological deficits or memory problems have been noted. The patient will be able to care for children.


1. The admission note indicates a patient diagnosed with major depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply.
a. Channeling excessive energy
b. Reducing guilty ruminations
c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardation

ANS: C, D, E
Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or meaning in life; thus, planning should include measures to accommodate psychomotor retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty ruminations.


2. A student nurse caring for a patient diagnosed with depression reads in the patient’s medical record, “This patient shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply.
a. Imbalanced nutrition: less than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia

ANS: A, C, D, F
Vegetative signs of depression are alterations in 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 diagnoses associated with feelings about self. See relationship to audience response question.


3. A patient diagnosed with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply.
a. Offer laxatives if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
d. Eliminate all daily caffeine intake.
e. Restrict intake of processed foods.

ANS: A, B, C
The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted. See relationship to audience response question.


4. A patient being treated with paroxetine (Paxil) 50 mg po daily for depression reports to the clinic nurse, “I took a few extra tablets earlier today and now I feel bad.” Which assessments are most critical? Select all that apply.
a. Vital signs
b. Urinary frequency
c. Psychomotor retardation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness

ANS: A, D, E
The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. The patient may have urinary retention, but frequency would not be expected.