Question 1

A client diagnosed with major depressive episode hears voices commanding self-harm.Which should be the nurse's priority intervention at this time?

Accepted Answer

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.

Question 2

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?

Accepted Answer

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.

Question 3

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?

Accepted Answer

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."

Question 4

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?

Accepted Answer

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.

Question 5

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?

Accepted Answer

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.

Question 6

In planning care for a suicidal client,which correctly written outcome should be a nurse's first priority?

Accepted Answer

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.

Question 7

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?

Accepted Answer

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.

Question 8

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?

Accepted Answer

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.

Question 9

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?

Accepted Answer

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."

Question 10

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?

Accepted Answer

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.

Question 11

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?

Accepted Answer

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.

Question 12

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?

Accepted Answer

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.

Question 13

A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT).What is the rationale for this procedure?

Accepted Answer

The nurse administers 100% oxygen during and after ECT to prevent anoxia resulting from medication-induced paralysis of respiratory muscles.

Question 14

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?

Accepted Answer

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.

Question 15

A nurse assesses a client suspected of having the diagnosis of major depressive episode.Which client symptom would rule out this diagnosis?

Accepted Answer

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.

Question 16

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?

Accepted Answer

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.

Question 17

Immediately after electroconvulsive therapy (ECT),in which position should a nurse place the client?

Accepted Answer

Rationale: The nurse should place a client who has received ECT on his or her side,to prevent aspiration.

Question 18

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?

Accepted Answer

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.

Question 19

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?

Accepted Answer

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.

Question 20

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?

Accepted Answer

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.

Quiz 16: Depressive Disorders

A client diagnosed with major depressive episode hears voices commanding self-harm.Which should be the nurse's priority intervention at this time?

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?

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?

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?

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?

In planning care for a suicidal client,which correctly written outcome should be a nurse's first priority?

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?

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?

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?

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?

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?

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?

A nurse administers 100% oxygen to a client during and after electroconvulsive therapy treatment (ECT) .What is the rationale for this procedure?

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?

A nurse assesses a client suspected of having the diagnosis of major depressive episode.Which client symptom would rule out this diagnosis?

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?

Immediately after electroconvulsive therapy (ECT) ,in which position should a nurse place the client?

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?

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?

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?