Question: A patient diagnosed with major depressive disorder 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. Select the nurse’s most effective approach to communication.
Answer Choices: a. Make observations on neutral topics. b. Ask the patient direct questions. c. Phrase questions to require “yes” or “no” answers. d. Frequently reassure the patient to reduce guilt feelings.
Answer: a. Make observations on neutral topics.
Question: A nurse is caring for a client who lost his mother to cancer last month. Which of the following statements made by the nurse is a nontherapeutic response?
Answer Choices: a. “Tell me more about how you are feeling.” b. “I understand just how you feel. I felt the same when my mother died.” c. “Let’s discuss how you have been coping.” d. “You sound angry. Anger is a normal feeling associated with loss.”
Answer: b. “I understand just how you feel. I felt the same when my mother died.”
Question: A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?
Answer Choices: a. Move in close to the client so you will not have to raise your voice. b. Walk away from the client and let him cool off. c. Request that other staff members remain close by to assist. d. Insist the client stop yelling and show appropriate behavior.
Answer: c. Request that other staff members remain close by to assist.
Question: A client tells a student nurse, “Don’t tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me.” Which of the following actions should the nurse take?
Answer Choices: a. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. b. Keep the client’s communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. c. Report the incident, but do not inform the client of the intention to do so. d. Keep the client’s communication confidential, but watch the client and his roommate closely.
Answer: a. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.
Question: A nurse is talking with a client who is at risk for suicide following the death of his spouse. Which of the following statements by the nurse is therapeutic?
Answer Choices: a. “Losing someone close to you must be very upsetting.” b. “I know how difficult it is to lose a loved one.” c. “I feel very sorry for the loneliness you must be experiencing.” d. “Suicide is not an appropriate way to cope with loss.”
Answer: a. “Losing someone close to you must be very upsetting.”
Question: A nurse is caring for a client who has a new prescription for disulfiram (Antabuse) for the treatment of her alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting if she drinks alcohol. This form of treatment is an example of which of the following?
Answer Choices: a. Aversion therapy b. Desensitization therapy c. Flooding d. Dialectical behavioral therapy
Answer: a. Aversion therapy
Question: In the emergency department, a patient’s vital signs are: blood pressure (BP), 66/40 mm Hg; pulse (P), 140 beats per minute (bpm); and respirations (R), 8 breaths per minute and shallow. The patient overdosed on illegally obtained hydromorphone (Dilaudid). Select the priority outcome.
Answer Choices: a. The patient will identify two community resources for the treatment of substance abuse by discharge. b. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute. c. The patient will be able to describe a plan for home care and achieve a drug-free state before being released from the emergency department. d. The patient will attend daily meetings of Narcotics Anonymous within 1 week of beginning treatment.
Answer: b. Within 8 hours, vital signs will stabilize as evidenced by BP greater than 90/60 mm Hg, P less than 100 bpm, and respirations at or above 12 breaths per minute.
Question: A patient being treated for major depressive disorder has taken 300 mg amitriptyline 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.” How should the nurse advise the patient?
Answer Choices: a. “Go to the nearest emergency department immediately.” b. “Do not be alarmed. Take two aspirin and drink plenty of fluids.” c. “Take one dose of the antidepressant, and then come to the clinic to see the health care provider.” d. “Resume taking the antidepressant for 2 more weeks, and then discontinue it again.”
Answer: c. “Take one dose of the antidepressant, and then come to the clinic to see the health care provider.”
Question: Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?
Answer Choices: 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.”
Answer: a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
Question: A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, “I feel like a failure. This baby is the root of my problems.” What is the priority nursing diagnosis?
Answer Choices: a. Insomnia b. Ineffective coping c. Situational low self-esteem d. Risk for other-directed violence
Answer: d. Risk for other-directed violence
Question: A patient diagnosed with major depressive disorder repeatedly tells staff members, “I have cancer. It’s my punishment for being a bad person.” Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.
Answer Choices: a. Powerlessness b. Risk for suicide c. Stress overload d. Spiritual distress
Answer: b. Risk for suicide
Question: Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food?
Answer Choices: a. Tomato juice b. Orange juice c. Hot tea d. Milk
Answer: d. Milk
Question: During a psychiatric assessment, the nurse observes a patient’s facial expressions that are without emotion. The patient says, “Life feels so hopeless to me. I’ve been feeling sad for several months.” How should the nurse document the patient’s affect and mood?
Answer Choices: a. Affect depressed; mood flat b. Affect flat; mood depressed
Answer: b. Affect flat; mood depressed
Question: A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. What action should the nurse take?
Answer Choices: a. Avoid forcing the issue. b. Bringing up the issue at the community meeting. c. Calmly telling the patient, “You must bathe daily.” d. Firmly and neutrally assisting the patient with showering.
Answer: d. Firmly and neutrally assisting the patient with showering.
Question: A patient was started on escitalopram 5 days ago and now says, “This medicine isn’t working.” What is the nurse’s best intervention?
Answer Choices: a. Discussing with the health care provider the need to change medications b. Reassuring the patient that the medication will be effective soon c. Explaining the time lag before antidepressants relieve symptoms d. Critically assessing the patient for symptom relief
Answer: c. Explaining the time lag before antidepressants relieve symptoms
Question: A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate?
Answer Choices: a. Arms crossed b. Staring at the nurse c. Smiling inappropriately d. Eyes casted downward
Answer: d. Eyes casted downward
Question: A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
Answer Choices: a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy. b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities. c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet. d. The patient needs time to reorient him or herself to a pressured work schedule.
Answer: a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.
Question: A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of what risk?
Answer Choices: a. Hypotensive shock b. Hypertensive crisis c. Cardiac dysrhythmia d. Cardiogenic shock
Answer: b. Hypertensive crisis
Question: The admission note indicates a patient diagnosed with major depressive disorder has displayed symptomology of both anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.)
Answer Choices: a. Channeling excessive energy b. Reducing guilty ruminations c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation
Answer: c. Instilling a sense of hopefulness d. Assisting with self-care activities e. Accommodating psychomotor retardation
Question: A student nurse caring for a patient diagnosed with major depressive disorder 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.)
Answer Choices: a. Imbalanced nutrition: less than body requirements b. Chronic low self-esteem c. Sexual dysfunction d. Self-care deficit e. Powerlessness f. Insomnia
Answer: a. Imbalanced nutrition: less than body requirements c. Sexual dysfunction d. Self-care deficit f. Insomnia