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Case Study Depression updated 2024
The nurse completes a physical assessment. When asked what brought her to the
hospital, the client replies that things just aren't right and begins to cry. After further
conversation, the client describes her mood as very sad now. She rarely goes out or
invites friends to visit. She admits that she feels like strangers are saying bad things
about her. Sometimes she hears a man's voice that is a little bit scary.
What is the priority nursing focused assessment?
- ask the client if she is hearing voices
- determine how long the client has been hearing the voice
- review the client's record for prior hospitalizations for depression
- have the client communicate where she is eeing the strangers - ANS; ask the client if
she is hearing voices
rationale: the nurse must assess the content of the auditory hallucinations for the
presence of command hallucination. Command hallucinations may be telling the client
to harm herself or others
How many points does the client have? (Enter the numerical value only. If rounding is
necessary, round to the whole number.)
Assessment of DepressionThe client's daughter, an only child who is visiting from out of
town, offers additional information about the client's behaviors. She tells the nurse that
her mother's clothes fit looser, and weight loss is evident. Current alcohol use is
suspected, and a breathalyzer is positive for alcohol use. The client denies current
suicidal ideation, but the nurse recognizes that the client has risk factors for suicide
based on the SAD PERSONS scale.The SAD PERSONS scale identifies ten
categories, and one point is assigned for each applicable category.
S = Sex. Men kill themselves more often than women, although women make more
attempts (score 1 if male; 0 if female).
A = Age. High-risk groups include 19 years of age or younger and 45 years of age or
older, especially the elderl - ANS; 6
The client is assessed by the nurse, a social worker, and the healthcare provider
(HCP). Based on their assessments, hospitalization is recommended for psychotic
depression
What behavior is inconsistent with depression?
- hearing a man's voice
- poor concentration
- poor grooming and hygiene
