A nurse discovers a client’s suicide note that details the time, place, and means to commit suicide. What should be the priority nursing action, and why?
- Administer lorazepam (Ativan) prn, because the client is angry about plan exposure.
- Establish room restrictions, because the client’s threat is an attempt to manipulate the staff.
- Place client on one-to-one suicide precautions, because specific plans likely lead to attempts.
- Call an emergency treatment team meeting, because the client’s threat must be addressed
Rationale: The priority nursing action should be to place this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide.
In planning care for a suicidal client, which correctly written outcome should be a nurse’s first priority?
- The client will not physically harm self.
- The client will express hope for the future by day three.
- The client will establish a trusting relationship with the nurse.
- The client will remain safe during hospital stay.
Rationale: The nurse’s first priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse’s first priority. Outcomes should be client-centered, specific, realistic, measureable, and must also include a time frame.
A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT). What is the rationale for this procedure?
- To prevent increased intracranial pressure resulting from anoxia.
- To prevent decreased blood pressure, pulse, and respiration owing to electrical stimulation.
- To prevent anoxia resulting from medication-induced paralysis of respiratory muscles.
- To prevent blocked airway, resulting from seizure activity.
Rationale: The nurse administers 100% oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles.
Immediately after electroconvulsive therapy (ECT), in which position should a nurse place the client?
- On his or her side, to prevent aspiration
- In high Fowler’s position, to prevent increased intracranial pressure
- In Trendelenburg’s position, to promote blood flow to vital organs
- In prone position, to prevent airway blockage
Rationale: The nurse should place a client who has received ECT on his or her side, to prevent aspiration.
A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?
- Altered communication R/T feelings of worthlessness AEB anhedonia
- Social isolation R/T poor self-esteem AEB secluding self in room
- Altered thought processes R/T hopelessness AEB persecutory delusions
- Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and grooming.
A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse’s priority intervention at this time?
- Obtaining an order for locked seclusion until client is no longer suicidal.
- Conducting 15-minute checks to ensure safety.
- Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
- Encouraging client to express feelings related to suicide.
Rationale: The nurse’s priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.
A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis?
- The client is disheveled and malodorous.
- The client refuses to interact with others and isolates self in room.
- The client is unable to feel any pleasure.
- The client has maxed-out charge cards and exhibits promiscuous behaviors.
Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode.
A client with a history of suicide attempts has been taking fluoxetine (Prozac) for one month. The client suddenly presents with a bright affect, rates mood at 9 out of 10, and is much more communicative. Which action should be the nurse’s priority at this time?
- Give the client off-unit privileges as positive reinforcement.
- Encourage the client to share mood improvement in group.
- Increase the level of this client’s suicide precautions.
- Request that the psychiatrist reevaluate the current medication protocol.
Rationale: The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behavior.
A nurse reviews the laboratory data of a client suspected of having the diagnosis of major depressive episode. Which lab value would potentially rule out this diagnosis?
- Thyroid-stimulating hormone (TSH) level of 25 U/mL
- Potassium (K+) level of 4.2 mEq/L
- Sodium (Na+) level of 140 mEq/L
- Calcium (Ca2+) level of 9.5 mg/dL
Rationale: A diagnosis of major depressive episode may be ruled out if the client’s lab results reveal a TSH level of 25 U/mL. Normal levels of TSH range from 2 to 10 U/mL. High levels of TSH indicate low thyroid function. The client’s high TSH value may indicate hypothyroidism, which can lead to depressive symptoms. The DSM-5 criteria for the diagnosis of major depressive episode states that this diagnosis must not be attributable to the direct physiological effects of another medical condition.
A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. Which theoretical principle best explains the etiology of this client’s depressive symptoms?
- According to psychoanalytic theory, depression is a result of negative perceptions.
- According to object-loss theory, depression is a result of overprotection.
- According to learning theory, depression is a result of repeated failures.
- According to cognitive theory, depression is a result of anger turned inward.
Rationale: The nurse should assess that, according to learning theory, this client’s depressive symptoms may have resulted from repeated failures. The learning theory is a model of “learned helplessness” in which multiple life failures cause the client to abandon future attempts to succeed.
What is the rationale for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive episode?
- The attention during the assessment is beneficial in decreasing social isolation.
- Depression can generate somatic symptoms that can mask actual physical disorders.
- Physical health complications are likely to arise from antidepressant therapy.
- Depressed clients avoid addressing physical health and ignore medical problems.
Rationale: The nurse should determine that a client with a diagnosis of major depressive episode needs a full physical health assessment, because depression can generate somatic symptoms that can mask actual physical disorders.
A nurse is planning care for a 13 -year-old who is experiencing depression. Which medication is approved by the Food and Drug Administration (FDA) for the treatment of depression in adolescents?
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexipro)
Rationale: Fluoxetine (Prozac) has been approved by the FDA to treat depression in children and adolescents, and escitalopram was approved in 2009 for treatment of depression in adolescents aged 12 to 17 years. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.
A nurse admits an older client with memory loss, confused thinking, and apathy. A psychiatrist suspects a depressive disorder. What is the rationale for performing a mini-mental status exam?
- To rule out bipolar disorder
- To rule out schizophrenia
- To rule out neurocognitive disorder
- To rule out personality disorder
Rationale: A mini-mental status exam should be performed to rule out neurocognitive disorder. The client may be experiencing reversible dementia, which can occur as a result of depression.
A nurse recently admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention, related to this medication, should be initiated to maintain this client’s safety upon discharge?
- Provide a 6-month supply of Elavil to ensure long-term compliance.
- Provide a 1-week supply of Elavil, with refills contingent on follow-up appointments.
- Provide pill dispenser as a memory aid.
- Provide education regarding the avoidance of foods containing tyramine.
Rationale: The health-care provider should provide no more than a 1-week supply of amitriptyline, with refills contingent on follow-up appointments, as an appropriate intervention to maintain the client’s safety. Antidepressants, which are central nervous system depressants, can be used to commit suicide. Also these medications can precipitate suicidal thoughts during the initial use period. Limiting the amount of medication and monitoring the client weekly would be appropriate interventions to address the client’s risk for suicide.
An older client has recently been prescribed sertraline (Zoloft). The client’s spouse is taking paroxetine (Paxil). A nurse assesses that the client is experiencing restlessness, tachycardia, diaphoresis, and tremors. Which complication should a nurse suspect, and why?
- Neuroleptic malignant syndrome; caused by ingestion of two different seratonin reuptake inhibitors (SSRIs)
- Neuroleptic malignant syndrome; caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI)
- Serotonin syndrome; possibly caused by ingestion of an SSRI and an MAOI
- Serotonin syndrome; possibly caused by ingestion of two different SSRIs
Rationale: The nurse should suspect that the client is suffering from serotonin syndrome; possibly caused by ingesting two different SSRI’s (sertraline and paroxetine). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor.
A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, “I heard about something called a monoamine oxidase inhibitor (MAOI). Can’t my doctor add that to my medications?” Which is an appropriate nursing response?
- “This combination of drugs can lead to delirium tremens.”
- “A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.”
- “That’s a good idea. There have been good results with the combination of these two drugs.”
- “The only disadvantage would be the exorbitant cost of the MAOI.”
Rationale: The nurse should explain to the client that combining an MAOI and fluvoxamine, an SSRI, can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches, with occasional photophobia, sensations of choking, palpitations, and a feeling of “dread.”
A number of assessment rating scales are available for measuring severity of depressive symptoms. Which scale would a nurse practitioner use to assess a depressed client?
- Zung Depression Scale
- Hamilton Depression Rating Scale
- Beck Depression Inventory
- AIMS Depression Rating Scale
Rationale: A number of assessment rating scales are available for measuring severity of depressive symptoms. Some are meant to be clinician administered, whereas others may be self-administered. Examples of self-rating scales include the Zung Self-Rating Depression Scale and the Beck Depression Inventory. One of the most widely used clinician-administered scales is the Hamilton Depression Rating Scale. The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that measures involuntary movements associated with tardive dyskinesia.
The severity of depressive symptoms in the postpartum period varies from a feeling of the “blues,” to moderate depression, to psychotic depression or melancholia. Which disorder is correctly matched with its presenting symptoms?
- Maternity blues (lack of concentration, agitation, guilt, and an abnormal attitude toward bodily functions)
- Postpartum depression (irritability, loss of libido, sleep disturbances, expresses concern about inability to care for baby)
- Postpartum melancholia (overprotection of infant, expresses concern about inability to care for baby, mysophobia)
- Postpartum depressive psychosis (transient depressed mood, agitation, abnormal fear of child abduction, suicidal ideations)
Rationale: The symptoms of the maternity blues include tearfulness, despondency, anxiety, and subjectively impaired concentration appearing in the early puerperium. Symptoms of postpartum depression are associated with fatigue, irritability, loss of appetite, sleep disturbances, loss of libido, and expressions of great concern about her inability to care for her baby. Both postpartum melancholia and postpartum depressive psychosis are characterized by a lack of interest in, or rejection of, the baby, or a morbid fear that the baby may be harmed. Other symptoms include depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions.
A staff nurse is counseling a depressed client. The nurse determines that the client is using the cognitive distortion of “automatic thoughts.” Which client statement is evidence of the “automatic thought” of discounting positives?
- “It’s all my fault for trusting him.”
- “I don’t play games. I never win.”
- “She never visits because she thinks I don’t care.”
- “I don’t have a green thumb. Any old fool can grow a rose.”
Rationale: Examples of automatic thoughts in depression include: Personalizing: “I’m the only one who failed.” All or nothing: “I’m a complete failure.” Mind reading: “He thinks I’m foolish.” Discounting positives: “The other questions were so easy. Any dummy could have gotten them right.”
A client, who is taking transdermal selegiline (Emsam) for depressive symptoms, states, “My physician told me there was no need to worry about dietary restrictions.” Which would be the most appropriate nursing response?
- “Because your dose of Emsam is 6 mg in 24 hours, dietary restrictions are not recommended.”
- “You must have misunderstood. An MAOI like Emsam always has dietary restrictions.”
- “Only oral MAOIs require dietary restrictions.”
- “All transdermal MAOIs do not require dietary modifications.”
Rationale: Selegiline is a Monoamine Oxidase Inhibitor (MAOI). Hypertensive crisis, caused by the ingestion of foods high in tyramine, has not shown to be a problem with selegiline transdermal system at the 6 mg/24 hr dosage, and dietary restrictions at this dose are not recommended. Dietary modifications are recommended, however, at the 9 mg/24 hr and 12 mg/24 hr dosages.
After 6 months of taking imipramine (Tofranil) for depressive symptoms, a client complains that the medication doesn’t seem as effective as before. Which question should the nurse ask to determine the cause of this problem?
- “Are you consuming foods high in tyramine?”
- “How many packs of cigarettes do you smoke daily?”
- “Do you drink any alcohol?”
- “Are you taking St. John’s wort?”
Rationale: Imipramine is a tricyclic antidepressant. Smoking should be avoided while receiving tricyclic therapy. Smoking increases the metabolism of tricyclics, requiring an adjustment in dosage to achieve the therapeutic effect. Alcohol potentiates the effects of antidepressants. Tyramine is only an issue when MAOI medications are prescribed. Concomitant use of St. John’s wort and SSRIs, not tricyclics, increases, not decreases the effects of the drug.
A nursing home resident has a diagnosis of dysthymic disorder. When planning care for this client, which of the following symptoms should a nurse expect the client to exhibit? (Select all that apply.)
- Sad mood on most days
- Mood rating of 2 out of 10 for the past 6 months
- Labile mood
- Sad mood for the past 3 years after spouse’s death
- Pressured speech when communicating
ANS: 1, 4
Rationale: The nurse should anticipate that a client with a diagnosis of dysthymic disorder would experience a sad mood on most days for more than two years. The essential feature of dysthymia is a chronically depressed mood, which can have an early or late onset.
An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should a nurse identify as most likely to contribute to the etiology of these symptoms? (Select all that apply.)
- Gender differences in social opportunities that occur with age
- Drastic temperature and barometric pressure changes
- A seasonal increase in social interactions
- Variations in serotonergic functioning
- Inaccessibility of resources for dealing with life stressors
ANS: 2, 3, 4
Rationale: The nurse should identify drastic temperature and barometric pressure changes, a seasonal increase in social interactions, and/or variations in serotonergic functioning as contributing to the etiology of the client’s symptoms. A number of studies have examined seasonal patterns associated with mood disorders and have revealed two prevalent periods of seasonal involvement: spring (March, April, May) and fall (September, October, November).
A client is prescribed phenelzine (Nardil). Which of the following statements by the client should indicate to a nurse that discharge teaching about this medication has been successful? (Select all that apply.)
- “I’ll have to let my surgeon know about this medication before I have my cholecystectomy.”
- “I guess I will have to give up my glass of red wine with dinner.”
- “I’ll have to be very careful about reading food and medication labels.”
- “I’m going to miss my caffeinated coffee in the morning.”
- “I’ll be sure not to stop this medication abruptly.”
ANS: 1, 2, 3, 5
Rationale: The nurse should evaluate that teaching has been successful when the client states that phenelzine should not be taken in conjunction with the use of alcohol or foods high in tyramine and should not be stopped abruptly. Phenelzine is an MAOI that can have negative interaction with other medications. The client needs to tell other physicians about taking MAOIs, because of the risk of drug interactions.
A nursing instructor is teaching about the new DSM-5 diagnostic category of disruptive mood dysregulation disorder (DMDD). Which of the following information should the instructor include? (Select all that apply.)
- Symptoms include verbal rages or physical aggression toward people or property.
- Temper outbursts must be present in at least two settings (at home, at school, or with peers).
- DMDD is characterized by severe recurrent temper outbursts.
- The temper outbursts are manifested only behaviorally.
- Symptoms of DMDD must be present for 18 or more months to meet diagnostic criteria.
ANS: 1, 2, 3
Rationale: The APA has included a new diagnostic category in the Depressive Disorders chapter of the DSM-5. This childhood disorder is called disruptive mood dysregulation disorder. Criteria for the diagnosis include, but are not limited to, the following. Verbal rages or physical aggression toward people or property; temper outbursts must be present in at least two settings (at home, at school, or with peers). DMDD is characterized by severe recurrent temper outbursts. The temper outbursts are manifested both behaviorally and/or verbally. Symptoms of DMDD must be present for 12, not 18 or more months to meet diagnostic criteria.