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Nursing Approach to Depression: Priority Assessments & Antidepressant Treatment, Exams of Nursing

A comprehensive guide on the priority nursing focused assessment for clients with depression, including the assessment of auditory hallucinations, the use of antidepressant medications such as fluoxetine, and the common side effects and precautions associated with these medications. It also covers the importance of communication techniques, safety precautions, and the role of electroconvulsive therapy and mao inhibitors in the treatment of depression.

Typology: Exams

2023/2024

Available from 04/13/2024

johnrays
johnrays 🇬🇧

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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
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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
  • slow motor activity - ANS; hearing a man's voice The nurse asks the client to sign the consent for treatment. If the client refuses treatment, which behaviors justify short-term involuntary treatment? (Select all that apply. One, some, or all options may be correct.)
  • unable to meet basic self-care needs
  • experiences auditory hallucinations
  • lives alone and lacks social support
  • prior hospitalizations for depression
  • states she has a plan to harm herself - ANS; unable to meet basic self-care needs, states she has a plan to harm herself The client signs the treatment form and is admitted to the mental health unit. During the first days of hospitalization, she begins antidepressant therapy with fluoxetine 10 mg In what classification of drugs is the antidepressant fluoxetine?
  • tricyclic
  • selective serotonin reuptake inhibitor (SSRI)
  • nonbenzodiazepine
  • atypical - ANS; SSRI What is the major action of SSRI antidepressants?
  • enhance GABA
  • potentiate serotonin and norepinephrine
  • increase availability of serotonin
  • stimulate the release of serotonin - ANS; increase availability of serotonin The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant therapy. What is the rationale?
  • tricyclics have more dangerous side effects
  • SSRIs are less likely to be abused
  • SSRIs are less likely to be abused
  • Tricyclics are less potent than SSRIs
  • SSRIs treat depression more effectively - ANS; tricyclics have more dangerous side effects When the client receives fluoxetine, the nurse must explain the purpose and when to expect therapeutic effectiveness. What should the nurse tell the client regarding when she will begin to feel less depressed?
  • generally within 2 to 4months
  • generally within 2 to 4 days
  • generally within 1 to 4 weeks
  • generally within 24 hours of taking the first dose - ANS; generally within 1 to 4 weeks The nurse should be aware of common side effects of SSRI antidepressants such as fluoxetine. Which side effect should be communicated to the client that commonly occur in clients who are taking SSRI antidepressants?
  • minimize caffeine in the morning
  • excuse the client from exercise - ANS; plan a scheduled rest period As the nurse initially communicates with the client, which communication technique is important?
  • acknowledge the client's courage in seeking help, then offer to sit quietly with the client
  • calmly reassure the client that everything will be fine
  • explain that antidepressants are the best treatment option
  • offer options for treatment that will support her needs - ANS; acknowledge the client's courage in seeking help, then offer to sit quietly with the client According to the nursing progress notes, the client demonstrates decreased social interaction, she rarely talks, she needs assistance to her room and appears confused. The client only slept 30 minutes in the past 24 hours, and the daily graphics indicate that she has slept an average of 2 hours in the past week. She is eating 50% of her meals. According to this data, what is the priority nursing problem?
  • disturbed thought processes
  • impaired social interaction
  • sleep disturbance
  • nutrition imbalance - ANS; sleep disturbance Since the client is eating 50% of her meals, which nursing intervention should be included on the treatment plan?
  • assess her appetite daily
  • include double portions of food
  • consult the unit dietician
  • weight weekly and document - ANS; weigh weekly and document One morning, the nurse takes the client's vital signs and notes her blood pressure is 141/108 mmHg. The progress notes indicate this is the third incidence of a high blood pressure.
  • fluoxetine has a side effect of hypertension
  • the client's diet, which consists of primarily high sodium foods, could be contributing to her high blood pressure
  • depression is a common cause of hypertension
  • higher blood pressure while hospitalized for a mental health issue is normal, and the blood pressure will resolve once the client is discharged - ANS; the client's diet, which consists of primarily high sodium, could be contributing to her high blood pressure The nurse reports the elevated blood pressure to the HCP, and the client is prescribed hydrochlorothiazide 25 mg by mouth (PO) daily. The nurse collaborates with the dietitians about the client's meal plan. Which dietary instruction should the nurse provide the client taking hydrochlorothiazide?
  • teach the DASH eating plan
  • tell the client to avoid kiwis and avocados
  • instruct the client how to choose a low-cholesterol diet
  • provide meal options to include high-protein, low-fiber - ANS; teach the DASH eating plan One morning, the nurse is doing unit rounds and finds the client sitting at the edge of her bed with a sheet around her neck. After removing the sheet, what is the next nursing action
  • ask the client if she is feeling suicidal
  • remain with the client
  • take the client to the seclusion room
  • document the incident in the chart - ANS; remain with the client The nurse stays with the client until another staff member arrives and safety precautions are initiated. A staff member must keep the client within eye sight at all times and document her activity every 15 minutes. When the client wants to change clothes and get ready for sleep at night, what should the staff do?
  • stay with the client while she gets ready
  • allow only 3 minutes for the client to dress
  • only allow the client to change in the bathroom
  • allow the client to change in the unit bathroom - ANS; stay with the client while she gets ready The client is placed on constant observation for safety precautions, so the nurse must assign a staff member to remain with her at all times. Which staff member is best to assign to the client?
  • registered nurse (RN)
  • male unlicensed assistive personnel (UAP)
  • medication nurse
  • female unlicensed assistive personnel - ANS; female unlicensed assistive personnel While the client is on constant observation, the nurse must assure that safety is maintained in the milieu. One afternoon, the nurse notices that a visitor brings some cans of the client's favorite soft drink. After ensuring the client is not on caffeine or sugar restrictions, what should the nurse do?
  • pour the soft drink into a paper cup
  • stay with the client when she is drinking the soda
  • explain to the visitor that soda is not allowed
  • ask the client to return the cans of soda to the visitor - ANS; pour the soft drink into a paper cup

The client receives only five ECT treatments because she refuses the IV insertion for the remaining treatments. When asked if she could tell a difference, she says "no." After additional months of therapy with multiple antidepressant medications (both SSRIs and tricyclics), the HCP considers treatment with an MAO Inhibitor. What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?

  • muscle stiffness and shuffling gait
  • diarrhea and increased thirst
  • confusion and sore throat
  • headache and palpitations - ANS; headache and palpitations The nurse plans to give the client a list of safe and unsafe foods that contain tyramine. Unsafe foods have high tyramine content, and safe foods have little or no tyramine. Which food would be considered safe?
  • most fruit
  • assorted cheeses
  • aged meats
  • imported beers - ANS; most fruits After several days of taking an MAO Inhibitor, the client refuses to continue taking the medication, and the medication is discontinued. Which specific nursing consideration is most important?
  • monitor blood pressure and orthostatic blood pressure
  • maintain a low-tyramine or tyramine-free diet for 10 to 14 days
  • arrange for liver function tests for hepatic dysfunction
  • assess the client's mood and affect - ANS; maintain a low-tyramine or tyramine-free diet for 10 to 14 days